





APPLICATION 



OP THE 



PHYSIOLOGICAL DOCTRINE 



TO 



SURGE R Y: 

Br L. J. BEGIN, M. D. 

EX-SURGEON AID-MAJOR TO THE MILITARY HOSPITAL OF INSTRUCTION OF METZ ; 

EDITOR OF THE CHIRURGICAL PART OF THE MEMOIRS OF MILITARY 

MEDICINE, SURGERY, AND PHARMACY, PUBLISHED UNDER THE 

SUPERINTENDENCE OF THE COUNCIL OF HEALTH OF 

THE ARMIES; AND MEMBER OF SEVERAL 

LEARNED SOCIETIES. 



TRANSLATED FROM THE FRENCH 

By WM. SIMS REYNOLDS, M. D. 




CHARLESTON : 

PRINTED BY E. J. VAN BRUNT, 



1835 



->. 



\* 



. v 



V 







Entered according to an Act of Congress in the year Eighteen 
Hundred and Thirty-Five, by Wm. Sims Reynolds, M. D. 
in the Clerk's office of the District Court of South- Carolina. 



Z/ff 



PREFACE 

OF THE TRANSLATOR. 



The science of medicine has been much improved of late, by 
the labours of French physicians ; and it is to Broussais and his 
followers that we are principally indebted, for the reformation 
which has taken place both in Medicine and Surgery. The 
growing importance and increasing popularity of the New Doc- 
trine, have caused many works involving its principles, to be 
translated into the English language ; but amongst them all, I 
have not yet seen one professedly treating of the application of 
the doctrine to Surgery. The subject is alluded to by some, and 
passed over in a cursory manner by others. M. Goupil, in his 
Exposition of the New Medical Doctrine, makes some few re- 
marks in relation to it, and concludes by referring the reader to 
the present work of M. Begin. It is with a view, therefore, of 
offering something upon this important subject, to those of the 
profession who are unacquainted with the original tongue, that I 
have undertaken the translation of the following pages. 



iv. PREFACE. 

It is unnecessary for us to say who the author of this work is : 
M. Begin has been long and favourably known as one of the 
most zealous advocates of the New Medical Doctrine ; and his 
Traite de Therapeutique, which was translated some years since, 
was universally allowed to be the ablest production of the Physi- 
ological school. 

On the merits and demerits of the New Medical Doctrine, 
enough has been said to preclude the necessity of my making any 
considerable comment here. That it contains errors, cannot be 
denied ; but that it is rich in benefits, must equally be admitted by 
every candid and intelligent physician. We may regard it as a 
new light emitting some of its luminous particles over the wide 
and extensive field that lies before us, dispelling some of the 
clouds and mists which have long hovered over it, exposing new 
paths, and pointing out new directions, to the wanderer after 
truth, and the impartial votary of science. It becomes us then, 
in relation to this as well as to every other doctrine, to select those 
truths which are consistent with our own reason and observation, 
and to reject those assertions which our experience does not 
sanction : in a word, 



doctrinam acri 



Judkio perpende ; et si tibi vera videter 

Dede manus— — aut si falsa est, accingere contra." — Lucret. 

I have endeavoured to give the reader a correct translation : 
whether I have succeeded or not, it remains for others to judge. 
Errors have occurred in the printing of the work which escaped 



PREFACE. V. 

my observation until it was too late to correct them : the most 
important of these, I have placed in the Errata ; the rest, the in- 
telligent reader will quickly detect, and alter for himself, 

Charleston, Feb. 1835. 



CONTENTS. 



Page. 

Preface of the Translator, .... . 

Preliminary Discourse, ... . . . . ix. 

Chapter I. Local affections produced by acute surgical 

lesions, . 27 

" II. Local treatment of acute surgical diseases, 35 

" III. Sympathetic phenomena determined by acute 

surgical lesions, . . . . . 64 

44 IV. Treatment of internal irritations which compli- 
cate surgical affections, ... 72 
44 V* Nervous affections determined by acute surgical 

lesions, ....... 94 

44 VI. Local alterations determined by chronic surgi- 
cal lesions, . . . . . .113 

44 VII. Local treatment of chronic surgical diseases, 138 
44 VIII. Sympathetic phenomena produced by external 

chronic irritations, . . . . . 188 

2 IX. Treatment of internal irritations which compli- 
cate chronic surgical diseases. . . . 205 



ERRATA. 



Page. Line. For. Read, 

30 2 of cancers which.. cancers, which 

" 13 effects effect 

41 20 farfor farfrom 

43 4 through.......... in 

45 15 circulating circulatory 

48 7 animal broths broths 

50 19 theyare.... it is 

" 21 them it 

51 8 they produce it produces 

52 1 ought to be necessarily ought necessarily to be 

58 18 supply supplies 

79 20 continued .continual 

91 4 depend depends 

96 17 24 The stupor stupor 

97 6 17 23 the stupor , stupor 

114 16 fistulas.. ....fistula? 

127 1 Chirurgical nosography The Chirurgical nosography 

149 15 is are 

152 22 parches parch 

180 5 have given give 

9 it depends they depend 

200 6 gives give 

205 8 this that 



PRELIMINARY DISCOURSE 



The domain of medicine is, they say, too 
extensive to be cultivated entirely, by a single 
individual. This proposition is not entirely 
correct. It might have suited an age when 
all diseases had their particular theory; when 
the history of each of them was composed 
almost exclusively, of the more or less fan- 
tastical assemblage of hypotheses advanced by 
authors upon this subject ; finally, an age in 
which there did not exist in physiology and 
pathology, any general principle founded upon 
observation, and which could serve as an on- 
ly and incontestable basis, to the history of the 
functions, as well as to that of diseases. Then, 
2 



X. PRELIMINARY DISCOURSE. 

without doubt, the best organized head, the 
mind the most studious and most opinionated, 
aided by the longest life, could not have been 
able to embrace all the parts of the science of 
man; that is to say, to retain and classify those 
contradictory opinions, those abstract theories, 
those incoherent results of observations disfi- 
gured by the imaginations of those who col- 
lected them, of which but lately the greatest 
part of medicine was still composed. 

These obstacles have almost entirely disap- 
peared in our day. The field of science has 
been disembarrassed of the useless materials 
which encumbered it ; and its soil, exposed to 
view, and cultivated in a manner more rational, 
is at length covered with rich harvests. On 
the one hand, all the doctrines which observa- 
tion does not sanction, are rejected, whatever 
may be the celebrity of their authors ; on the 
other hand, all the results which appear to be 
the exact expression of facts, are admitted, in 
spite of the opposition that may exist between 



PRELIMINARY DISCOURSE. XI. 

them and tl\e most accredited ancient theories. 
It is only by proceeding with this vigour and 
this independence, that we can arrive at the 
perfection of Physiology and Pathology. 

Great advancements have been made to attain 
this end; and if new investigations are still ne- 
cessary, we ought to hope that they will serve 
very soon to elevate medicine to that degree of 
certainty and regularity which distinguishes ac- 
tually physics and chemistry. Already do the 
general principles established and universally 
adopted, permit us to have a glimpse of that 
happy epoch ; and as these principles are. actu- 
ally in relation with the amount of the known 
facts, it is very probable that future discoveries 
will serve to confirm still more, their exact- 
ness. 

These improvements are common to medi- 
cine and to surgery ; for both ought to found 
their basis on pathological physiology. To 
maintain that surgery consists in nothing more 
than the application of mechanical means to 



XII. PRELIMINARY DISCOURSE. 

the body of man, is to give it an incorrect defi- 
nition ; and which, contradicted by the actual 
nature of things, could not be just, but in the 
ages when this science was cultivated by physi- 
cians, or when the performance of operations 
was abandoned to the hands of the ignorant 
and barbarous. This definition only serves to 
restrict the ideas of students who are destined to 
undergo a surgical course, and to make them 
believe that they can keep within the bounds 
of the list of operators. The surgeon has a 
task more important and more noble to fulfil. 
At the same time that he devotes himself espe- 
cially to the performance of operations, he ought 
to make an especial object of study, the diseases 
which require the employment of those extreme 
resources of a conservative art. There exists, 
therefore, one part of pathology, which forms 
in some sort, the particular dominion of sur- 
gery. 

But in adopting such a principle, it must not 
be forgotten, that the affections termed surgical? 



PRELIMINARY DISCOURSE. Xlll. 

are constantly complicated either with derange- 
ments in the rhythm and intensity of the organic 
movements, or the result more or less slow of mod- 
ifications contributing to the exercise of these 
movements. The surgeon cannot forget without 
danger in practice, that at the same time that he 
remedies by operations the derangements of our 
parts, he acts upon sensible, irritable tissues 
disposed to become the seat of violent inflam- 
mation, and united to the principal viscera of 
the living economy, by sympathies more or less 
close. He ought to remember, moreover, that 
medicinal means properly administered, often 
render unnecessary the most serious operations, 
and are constantly necessary to facilitate and 
secure the success of these operations. 

It is therefore indispensable, that the practi- 
tioner who makes surgery his principal occupa- 
tion, be at the same time a skilful physician : 
he ought to know both the anatomical disposi- 
tion of the diseased parts, and the laws which 



Xiv. PRELIMINARY DISCOURSE. 

preside over their functions and the manner in 
which the tissues are affected by the lesions 
which he remedies. Without this knowledge 
in some measure preliminary, how can he judge 
of the necessity of performing most opera- 
tions ? If he is ignorant of the laws of the 
sympathies, how can he institute an internal 
and external methodical treatment % how can 
he prepare the patient to support the action of 
instruments, and prevent or combat the affec- 
tions which that action frequently determines. 
The surgeon who would confine himself to 
manual operations, would be only an ignorant 
and rude workman ; knowing neither the dispo- 
sition nor the properties of the matter upon 
which he acts, we would see him in his blind 
and undeviating attempts, commit at each step 
the most fatal errors. 

The practitioners who cultivate surgery espe- 
cially, could not evidently remain strangers to 
the improvements of medicine, without inces- 
santly compromising the honor of the art, and 



PRELIMINARY DISCOURSE. XV. 

without exposing the afflicted to the most serious 
accidents. But it is incontestable, that it is on- 
ly within a few years, that the physiological doc- 
trine has given to medical studies and* practice 
a new impulse, and has rendered them eminent- 
ly philosophic. The actions and sympathies of 
different organs better known ; the nature, the 
immediate effects and remote results of irrita- 
tions, explained with exactness ; the theory of 
inflammations and of hemorrhages called pas- 
sive, brought to light ; the etiology and the prin- 
cipal phenomena of scurvy, explained by an un- 
expected alteration in the composition of the 
nutritive materials ; the entire class of essential 
fevers effaced from the tables of nosology ;* final- 
ly, this grand principle, that all diseases consist 
in the lesion of one or more organs, established 
upon immoveable foundations : such are some of 

* Among the works best written, and which are the most 
proper to place beyond doubt the true nature of ievers, we 
cannot too often cite the excellent Pyretologie Physiologique, 
recently published by M. Boisseau. This book is remarkable 



XVI. PRELIMINARY DISCOURSE. 

the ameliorations accruing to the history of dis- 
eases, by the new doctrine. The works of M. 
Broussais, and those of the physicians of the phy- 
siological school, have given to the science a 
new aspect : it appears that by their efforts, ob- 
servation has been rendered more scrutinizing, 
experience more sure, and medical reasoning 
more luminous and more productive. 

If any thing ought to be surprising in the 
midst of the general agitation of minds, it is, 
that surgery has participated scarcely any, in 
the recent improvements in pathological physi- 
ology and internal medicine. It suffices to 
open the most esteemed elementary works, 
those which have been published most recently 
upon the science, to be convinced of this truth. 
Their authors appear to have uudertaken the 
task of reviving the most antiquated opinions, 
of sustaining errors the most completely refuted, 

for the talent which has presided over its composition, for a criti- 
cism of the ancient theories as luminous as just, and for the 
solidity of the proofs which it contains in favour of the soundest 
doctrines. 



PRELIMINARY DISCOURSE. XV1J. 

and of religiously preserving, even the most 
dangerous therapeutical principles. 1 need not 
cite any of those books; we can easily perceive 
the hypothetical doctrines, the humoral, me- 
chanical, or Brunonian theories which they 
contain in each page. 

A small number of isolated observations, rel- 
ative to the treatment of certain acute or chronic 
inflammations of the external parts of the body, 
by leeches and topical emollients, constitutes 
almost all that we possess, relative to the appli- 
cation of the physiological doctrine to surgery. 
M. Gama, chief surgeon to the military hos- 
pital of instruction at Strasburg, has, however, 
composed upon this fruitful subject, a discourse 
too little known, but remarkable for profound 
and attentive observation, and for considera- 
tions as extensive as judicious. In fine, if I 
were permitted to mention myself here, I would 
claim the honor of having a long time since, 
and perhaps one of the first, applied the princi- 
ples of the new doctrine, to the theory and 
3 



XV111. PRELIMINARY DISCOURSE. 

treatment of surgical diseases.* But it remain- 
ed to consider the lesions of the external parts of 
the body in their ensemble, to make obvious 
the general laws according to which the local 
and sympathetic phenomena which they deter- 
mine, manifest themselves ; and finally, to es- 
tablish the most rational basis of treatment 
which it is proper to oppose to them. All sound 
minds, convinced that physiological medicine 
ought to be as useful to surgery as to internal 
pathology, have waited impatiently for a work 
appropriated to the demonstration of this truth : 
it is this desire which I have endeavoured to 
satisfy in the following pages : happy, if in 
spite of my efforts, I have not remained too 
far below the object which I have wished to 
attain. 

I am far from having embraced in this work, 
the whole dominion of surgery. There is, more- 
over, an important part of this science which 

* fcee the articles, Abces, Articulation, Arthrocace, Blessure, 
Brulure, Carie, Cerveau, Crane, Dent, Fistule, Fracture, En- 
torse, &c. in the Dictionnaire abrege des sciences medicales. 



PRELIMIN4RY DISCOURSE. XIX. 

has no need of examination or revision, and 
which has not occupied my attention : it is that 
which has for its object, the study of the mech- 
anism by which certain physical lesions are 
produced, and the descriptions of the practical 
proceedings and methods of operating. Here, 
all is after a certain manner, we may say, sub- 
ject to calculation; the true principles, if not 
the limits of the art, are fixed; and the different 
systems of pathology, can have no influence, 
either upon their theory or their practice. 

Whatever may be the extent, which I have 
been able to give to my labour, it was equally 
impossible for me to embrace, all the particular 
cases, in which could be made a useful appli- 
cation of physiological medicine to surgery : 
Thus, fractures of the scull; the disturbances, 
contusions, and separations of the brain and 
its membranes ; the solutions of continuity in 
the thoracic and abdominal viscera; the san- 
guineous, purulent, or serous effusions into the 
cavities of the pleura, or of the peritoneum: 



XX. PRELIMINARY DISCOURSE. 

the various lesions and abscesses of the liver f 
intestinal incarcerations; foreign bodies lodged 
in the digestive canal: these are some of the 
lesions, the methodical treatment of which, re- 
quires a thorough knowledge of the new med- 
ical doctrine. 

Wishing then to Compose, not so much a 
treatise on surgery, as a sort of introduction to 
the study of that important branch of the heal- 
ing art, and being obliged to confine myself to 
general rules on the theory and treatment of 
surgical lesions, and the affections which may 
complicate them, the plan which 1 have follow- 
ed, although very proper to fulfil my views, may 
appear, perhaps, not sufficiently methodical; ne- 
vertheless, I could not adopt the classification of 
the diseases in physical, vital, and organic le- 
sions; simple, it is true, but anti-physiologick. 
The greatest part of physical lesions, are, in 
effect, constantly followed, either immediately, 
or after a very short time, by derangements in 
the rhythm and force of the organic movements. 



PRELIMINARY DISCOURSE, XXI. 

It is for this reason, that wounds, fractures, 
and luxations, give rise always, to inflamma- 
tions more or less lively, and ordinarily so 
intense, that it does not suffice merely to re- 
unite or to replace the parts, but also, to prevent 
or to combat in an energetic manner, their irri- 
tation and its effects. The vital lesions, in their 
turn, determine, in nearly all subjects, alterations 
more or less profound, in the texture of the parts 
of which they are the seats ; alterations which 
constitute, notwithstanding what may be said, 
true organic lesions. Finally, the degeneracies 
of the living tissues, the development of new 
pathological tissues, are constantly and exclu- 
sively the result of vital lesions, which, after 
having formed those tissues, are enlarged, and 
preside over the numerous transformations 
which they are to undergo. In all cases of 
schirrus, cancer, melanose, etc. it is the irri- 
tation, or the vital lesion, which is the near- 
est and direct cause of the morbid organic 
production: the last is but an effect, a conse- 



XX11. PRELIMINARY DISCOURSE. 

quence of the other: it ought not to excite 
more than secondarily, the attention of the 
physiologist and the practitioner. We must 
then admit, ultimately, that vital lesions ac- 
company, almost always, physical lesions; and 
that organic lesions are constantly produced, 
kept up, and modified, by the same vital le- 
sions. What confidence can one give to a 
classification which enjoys in so high a de- 
gree, the privilege of separating arbitrarily, that, 
which in nature, is always one and indivisible ? 
I have then to follow another route. It ap- 
pears to me agreeable to divide surgical diseases 
into two grand classes, the one to comprehend 
the acute lesions, and the other the chronic 
affections. Among the first, I arrange those 
diseases which appear rapidly, and which have 
a tendency to run their course in a very short 
time: such are wounds, fractures, contusions, 
and violent inflammations. It belongs less to 
me to examine those lesions, in relation to their 
etiology, and the mechanical operations which 



PRELIMINARY DISCOURSE. XXlll. 

they require, than with respect to the local arid 
general affections of which they are the source, 
the influence which they exert upon the princi- 
pal viscera, and the medicinal remedies, internal 
or external, by which they may be counteracted. 
Such are the subjects which are treated of, in 
the first five chapters of the work. I have 
afterwards collected under the title of chronic 
surgical lesions, all those which succeeding to 
the former, or which developed by other causes, 
have a prolonged, and as it were, indefinite 
existence. I have endeavoured to trace back 
as far as the vital lesion which provokes and 
keeps up the most important affections of this 
kind, in order to establish on solid founda- 
tions, both the curative indications which they 
present, and the treatment the most proper to 
combat them. After having examined the sym- 
pathetic influence exercised by chronic surgical 
diseases, whether on the whole of the animal 
organization, or aspecially on different parts of 
the body, it has been easy for me to point out the 



XXIV. PRELIMINARY DISCOURSE. 

means that should be employed to remove these 
secondary affections, and show in what should 
consist, the preparation which the patients 
should undergo before performing great oper- 
ations. But having spoken in the first chap- 
ter, of the effects of these operations themselves, 
and exposed the treatment which those oper- 
ated upon should claim, the sufficiently extended 
circle of ideas which I proposed .to myself to 
develop, was finished. 

I may be reproached, perhaps, for not having 
presented in this work, any considerations on 
surgical diseases which may be said to arise 
from the debility of certain tissues, or of the 
entire organization. I am far from denying 
the existence of this class of lesions ; but they 
do not appear to be quite as extended as certain 
persons think. Besides, other things of more 
importance demand our attention; and as there 
has been so deplorable an abuse made of stim- 
ulants, in surgery as well as in medicine, and 
the methods of strengthening the parts, or the 



PRELIMINARY DISCOURSE. XXV. 

whole of the animal economy, so much extend- 
ed and perfected, that it is actually less neces- 
sary to show when these methods should be 
employed, than to point out the more numerous 
cases, in which they are injurious. 

Finally, I have endeavoured in this work, 
to give physiological reasonings for a basis to 
surgical pathology and therapeutics. Certain 
persons, enemies to all researches, all reflection, 
I will say, to almost all theories founded upon an 
observation of the laws of the living organiza- 
tion, will accuse me, perhaps, of temerity. Ne- 
vertheless, there must be, at some future day, a 
wholesome physiology, that will enlighten and 
command all medical sciences; it is indispensa- 
ble, that it should extend its empire over lesions, 
the theory and treatment of which, seem neces- 
sarily to have escaped its influence. Men who 
actually deny the importance of physiological 
medicine, the rapidity of its progress, and the 
happy results which it produces, resemble the 

sophist who denied the reality of motion, even 
4 



XXVI. PRELIMINARY DISCOURSE. 

when he saw his adversary walking before him : 
but neither their obstinacy, nor their efforts, will 
be able to hinder the medical revolution which 
is in operation, from receiving its entire devel- 
opment. 



APPLICATION 



QF THE 



PHYSIOLOGICAL DOCTRINE. 



TO SURGERY. 



Chapter L 

Local affections produced by acute surgical 

lesions. 

Inflammation supposes always the previous 
action of an irritating cause, upon the tissues 
which are its seat. This action determines the 
acceleration of the local organic movements, 
or irritation. 

The afflux of the fluids, the engorgement of 
the capillary vessels, the passage of the red 
globules of blood into the canals which do not 
admit them during a normal state, and as a con- 
sequence, the swelling, heat, pain, and redness 



28 PHYSIOLOGICAL DOCTRINE, 

of the part; such are the results, more or less 
immediate, which irritation carries after it. If 
the acceleration of the organic movements be 
recent, the attracted fluids are not yet combined 
with the organic structure. By soaking the 
inflamed tissues in water, and washing them 
repeatedly after death, we may succeed very 
easily in getting rid of the whole of the red 
colouring matter, and restore them to their ori- 
ginal size and appearance. But, if the local 
afflux has persisted for a longer time, the glob- 
ules of blood combine in some sort with the 
parenchyma of the part effected; they appear 
to make an integral part of it, and we cannot 
detach them from it, by any mechanical pro- 
cess. Some persons have proposed to designate 
the first of these states, by the name of conges- 
tion or fluxion ; and not to give to any but the 
other, the title of inflammation. Without en- 
tirely rejecting this distinction, it would not be 
right to attach to it too much importance ; for, 
as Bichat has observed : the state of freedom 
or combination of the attracted fluids in the 
irritated parts, is only a secondary phenomenon, 
a consequence of irritation. This constitutes 



APPLIED TO SURGERY. 29 

alone, that which is truly fundamental in in- 
flammatory diseases : it alone determines the 
more intense sympathetic phenomena, indepen- 
dently of the material alterations of the effected 
organs. 

Whenever an irritation developes itself in a 
part of the living body, we see a process com- 
mence, which can be terminated by a prompt 
healing, or by the destruction and death of 
the inflamed tissues or by the slow degen- 
eration and complete disorganization of these 
same tissues. In the first case, the irritation 
being abortive at its birth, if 1 may use the 
expression, we observe a more or less rapid res- 
olution of the inflammation ; or else, the phlo- 
gosis determining the secretion of a particular 
fluid, suppuration takes place. In the second, 
the parts not being able any longer to support 
the excess of action which their irritation im- 
posed, cease to live, and become gangrenous. 
Lastly, in the third, the stimulation continuing 
itself in a slight degree, the nutrition of the 
organs which it usurped, is modified ; their pa- 
renchyma looses its physical properties ; its as- 
pect is changed; and we see developed, masses 



30 PHYSIOLOGICAL DOCTRINE, 

or thin plates of fibrous, cartilaginous, and scir- 
rhous tissues; and finally, of cancers which 
extend their ravages very far. The most sim- 
ple acute irritation, that which aggravates a 
wound otherwise slight, may determine each of 
the phenomena which I have just enumerated. 

The consideration of the different shades of 
alteration which the inflammed parts may pre- 
sent, merits, nevertheless, to fix the attention 
of the practitioner: it permits him frequently 
to discover, by a simple inspection of the or- 
gans, the violence and duration of the phleg- 
masia which effects them. The skilful and 
experienced observer, by examining with atten- 
tion the traces which complicated diseases leave 
after them on dead bodies, can distinguish the 
parts which have been the seat of recent and 
sympathetic phlegmasise, from those on which 
irritation first made its invasion. 

These general principles being admitted, we 
will examine the influence which they ought to 
exercise, over both surgical theory and practice. 

All bodies capable of wounding our organs, 
may act as very powerful causes of irritation. 
When a part has been violently contused, its 



APPLIED TO SURGERY. 31 

tissue separated and has experienced a rough 
and sudden displacement, we very soon observe 
the organic movements of the part become 
more violent, and the fluids penetrate its tissue 
in a greater quantity than in the normal state. 
An inflammatory swelling proportionate to the 
susceptibility of the individual, and the degree of 
local sensibility, as well as the more or less vas- 
cular texture of the parts, appears in some cases, 
and extends to some distance. The irritated 
tissues then acquire new properties : they are 
more red, and more compact; their functions 
cannot be exercised but with great difficulty; 
and many others of these, such as the cellular 
tissue and serous membranes, become inexten- 
sible and easy to tear, whether we wish to stretch 
them out, or tie them by means of ligatures. 
This last disposition, we may remark en pas- 
sant, is the cause of the little success which fol- 
lows the tying of arteries at the points where 
the cellular coat of these vessels is already in- 
flamed. In such cases, we observe the cellular 
tissue to be cut under the threads; and as the 
middle coat of the artery is inevitably likewise 
cut, the internal coat, which alone remains un- 



32 PHYSIOLOGICAL DOCTRUNE, 

injured, being too feeble to resist the force of 
the blood, it breaks, and haemorrhage takes 
place.* 

Irritation, and the inflammatory action which 
it produces, are, when they become too consid- 
erable, almost the exclusive causes of all the 
danger to which the patient is exposed, by those 
surgical lesions, of which death is not the im- 
mediate and mechanical result. After wounds 
of the brain, the lungs, and the abdominal vis- 
cera, if the person does not perish at the in- 
stant when he receives the wound, the period 
when the inflammation of the parts injured by 
the wounding body develops itself, is that, when 
life will be most strongly menaced. If no vio- 
lent inflammation manifests itself after lesions 
of the external parts of the body, we will never 
observe either those acute fevers which cause 
the wounded very often to succumb, or those 
enormous swellings, in which the termination 
most ordinarily consists, either in the formation 
of large and multiplied abscesses, or in in- 
exhaustible suppurations, or finally, in those 



, — 



* Vide — Sabatier's Medicine Operatoire, nouvelle edition, tome 
1 , Prolegomenes. ; 



APPLIED TO SURGERY. 33 

intense gangrenes which allow of na other re- 
source than the amputation of the limbs. 

Inflammation is, nevertheless, an action of 
the living parts, without which, none of the 
wounds inflicted upon organized beings can be 
cured. Under this relation, it is the most pow- 
erful agent which nature employs to remedy 
the lesions of the organization. But for it to 
be salutary, this inflammation should be confin- 
ed within just bounds, and consist only in that 
degree of excitation which is indispensable for 
the displacement of disorganized parts, and the 
formation of cicatrices. 

The human body, in the case which we now 
consider, is not susceptible of contracting sev- 
eral kinds of inflammations, some of which 
might be adhesive, the others suppurative, or 
ulcerative, etc. We observe in nature, only 
different degrees of intensity, in inflammatory 
actions; degrees which produce varied results, 
by reason either of the disposition of the af- 
fected parts, or the more or less considerable 
quantities, or different qualities of the fluids 
which penetrate them. 
5 



34 PHYSIOLOGICAL DOCTRINE, 

Not only does irritation and inflammation of 
the living tissues succeed constantly to lesions 
produced by external bodies, but these affections 
are the inevitable result of most of the opera- 
tions of surgery. Make an opening in the pa- 
rieties of the chest, penetrate into the bladder 
to take out a foreign body, extirpate a cancer- 
ous tumour; finally, cut off a member entirely; 
you will always observe an irritation develop 
itself in the parts which the instrument has 
divided, and often extend itself, by continuity of 
tissue, or by sympathy, to organs quite remote; 
and as after accidental wounds, if the patient 
does not sink immediately, either from pain, or 
loss of blood, the period of the development of 
inflammation, will be that when life will run 
the greatest risk. The surgeon can never for- 
get this important observation without danger: 
it ought to serve as the basis of his practice. 



APPLIED TO SURGERY. 35 

Chapter II. 

Local treatment of acute surgical diseases* 

It results from the preceding considerations, 
that in all cases, either of external injuries, or 
surgical operations, the most formidable affec- 
tion which the practitioner has to contend with, 
is the local inflammation which has to develop 
itself. It is not necessary for us, notwithstand- 
ing, to endeavour to hinder entirely, the mani- 
festation of inflammatory action. This end 
cannot be attained ; nature herself having an 
irresistible tendency to produce an afflux of the 
fluids to the stimulated parts. Besides, even 
when such an indication could be fulfilled it 
would be hardly right to undertake it, as it is 
only by means of an indispensable inflammation 
that the cure is effected. Neither should we, in 
the treatment of wounds, bruises, and other af- 
fections of the same kind, endeavour to produce 
the development of an adhesive or resolutive 
inflammation, at the same time that we use our 
efforts to repress suppurative or gangrenous in- 
flammations. To adopt a similar language, it 



86 PHYSIOLOGICAL DOCTRINE, 

would be to enter anew into the domain of 
hypothesis or useless abstractions : it would be 
to substitute methaphorical and inexact ex- 
pressions, for such as are always simple on 
account of their truth. Under the circumstan- 
ces which we are placed, the practitioner ought 
to confine himself exclusively, to moderating 
the inflammatory action which is about to de- 
velop itself in the wounded parts, and to keep it 
in those bounds, where it is advantageous with- 
out the power of becoming hurtfuL 

After having reduced the fractures and luxa- 
tions, reunited the simple wounds, and dressed 
those properly which are bruised, lacerated, or 
accompanied by a loss of substance, he should 
employ the general and local anti-phlogistic 
means most proper to prevent the occurrence of 
serious accidents. General blood-letting and 
local applications ; at the same time anodynes 
and resolutives are perfectly adapted to the first 
stage of the wound. If the skin is cut and sup- 
puration inevitable, it would be advantageous 
to cover the wound with nothing but dry lint. 
It is almost useless to add, that rest of the 
whole body, and especially of the part effected. 



APPLIED TO SURGERY. 37 

soothing drinks, and the more or less complete 
abstinence from all solid food, are the means 
which he should add to those of which I have 
already spoken. 

The combination of these first mentioned 
medications has for its object : 1st, to diminish 
the quantity of blood which becomes a very 
powerful secondary cause of augmenting the 
pain and local irritation whenever it penetrates 
with abundance the already stimulated parts ; 
2nd, to render this fluid more serous, and to sus- 
pend the introduction of the nutritive materials 
which serve to regenerate it : we have observed 
that it is much more exciting, and, of course, 
much more hurtful to irritated organs, when it 
contains a greater proportion of nutritous par- 
ticles, and that it is more rich from principles 
furnished by an animal diet : 3d; lastly, to relax 
the whole of the organization, to diminish the 
stimulation of the principal viscera, and, in ren- 
dering the sympathies less active, to prevent 
the development of a part of those serious af- 
fections of which they are the source. 

Do the local bleedings which are so useful 
in the more advanced stages of the disease, 



38 PHYSIOLOGICAL DOCTRINE^ 

have the same efficacy in the first moments 
which follow the wound, and before the inflam- 
matory action has commenced ] The cause of 
the inflammatory congestion about to take place, 
consists at this time entirely, it is true, in the 
wound itself, that is to say, in the contusion, 
laceration, or division of the tissues : It is still 
independent of the presence of blood, since 
there does not exist any engorgement of the 
affected parts. It may be thought, even, that 
local bleeding can neither modify in any nota- 
ble manner the impression which the parts have 
received, nor, as a consequence, diminish the ef- 
fects which it ought to produce. Nevertheless, 
leeches applied immediately after the accident, 
to the parts contused, distended, affected with 
sprains, fractures, or other affections of the same 
kind, have been very advantageous. They seem, 
at the time, to prevent the local congestion; and 
their bites yet bleeding at the time of the afflux 
of the fluids, furnish an easy issue to the blood, 
which drains out in proportion as it is drawn 
into the parts by irritation : in this manner the 
cappillary system cannot be engorged to any 
great extent, and the phlogosis miscarries, in a 



APPLIED TO SURGERY. 39 

maimer, before birth. You must not however, 
abuse these local preservative bleedings ; they 
are not indispensable, and in general, we ought 
to have recourse to them only in cases of ex- 
tensive and serious injuries, and especially in 
wounds of the viscera. The simple and su- 
perficial affections, at first, require only the 
employment of the topical emolients and res- 
olutives, of which I have already spoken. 
Those substances which do not irritate, such 
as a small solution of the acetate of lead, or 
cold water a long time continued, diminish di- 
rectly the stimulation and pain of the injured 
parts ; they attack even the principle of the 
disease ; and it would not be right to abandon 
entirely their use after fractures, distensions of 
the fibrous tissues, or contusions of our organs. 
These topical applications, no doubt, may not 
succeed completely in all cases; but, aided by 
the other medications which have been men- 
tioned, they contribute to render the excitation 
of the tissues less lively, and the inflammation 
which it determines less considerable. 

There is, besides, another remedy which has 
been put in use, with the greatest success, in 



40 PHYSIOLOGICAL DOCTRINE, 

cases of contusion, sprain, and those of. wounds 
of the soft parts, and which assists very much 
the preceding remedies in preventing the in- 
flammatory fluxions, and diminishing their vio- 
lence : that remedy is compression. Extolled 
with a little exaggeration, perhaps, by the En- 
glish surgeons, and among others, by Dr. J. 
Young, compression has been used for a long 
time with the greatest success, in those cases 
in which it has been used by M. Dupuytren: 
its effects seemed often wonderful. It appears, 
by bringing nearer, and making more firm the 
contused or drawn parts, and in diminishing the 
capacity of all the vessels, to oppose the access 
of blood into the diseased part and to hinder 
somewhat the inflammation. Practiced on the 
muscles, it hinders their contraction, and main- 
taining the luxated bones or fractures in their 
situation, it opposes the new irritation which 
they would determine, if their displacement 
was reproduced. But, for it to be salutary, 
the compression ought to extend from the por- 
tion of the member the most distant from the 
body, to above the wounded part. This dispo- 
sition is necessary, in order to prevent the ab- 



APPLIED TO SURGERY, 41 

struction of the inferior part of the extremity. 
It is likewise necessary that the compression 
have not more than a moderate degree of force, 
to fulfil the indication which we propose ; if 
more violent, it would be painful and injurious; 
and in augmenting the irritation it would in- 
crease the danger of the patient. Compression, 
finally, is rendered more efficacious when we 
dip the bandages and compresses which are 
used, in some resolutive liquor; or when we 
sprinkle them continually with cold water. 

The most judicious surgeons have, for a long 
time, sanctioned the propriety of that common 
custom which consists in covering the wounded 
parts with a solution of the muriate of soda, 
wine, or camphorated spirits, and some other 
topical irritants which they lavish in great 
abundance in cases even of wounds of fire-arms. 
Experience has proved, that these liquids, far 
from preventing or moderating the swelling and 
inflammation, are only proper tp hasten the 
moment of their appearance, and to render them 
more considerable, by augmenting the excita- 
tion of the parts. Pure water has seemed, with 
reason, to be the topical remedy the most sim- 
6 



42 PHYSIOLOGICAL DOCTRINE, 

pie and the most salutary which we can employ 
in a great number of cases. Applied cold and 
for a space of time sufficiently long, it eases 
promptly, the pain ; opposes the effects of the 
stimulation produced by the wound ; and the 
afflux of the fluids. Employed lukewarm, when 
the inflammation is developed, it possesses in a 
high degree an emollient property : it calms and 
relaxes the tissues, it moderates the organic 
movements, and favours very much the termi- 
nation of the inflammation by resolution. It 
may be recollected, that it is in the military 
hospital of Strasburg, that experiments have 
been made by Lombard, one of the most learn- 
ed military surgeons, and by the illustrious acad- 
emist Percy, which have most contributed to 
verify the good effects of water in the treatment 
of surgical diseases. I have myself employed 
it many times in the army, in cases of gun-shot 
wounds of the hands, or in the neighborhood of 
articulations, and have never failed with it, nor 
have I found that the above gentlemen, have 
overrated the advantages which are to be deri- 
ved from it. 



APPLIED TO SURGERY. 43 

It would be superfluous to say much of mak- 
ing incisions for the purpose of dividing the 
adhesions following the wounds of fire-arms, or 
punctures through the members which are sur- 
rounded by strong aponeuroses : the utility of 
these operations, considered as the means of 
rendering local inflammation less violent and 
less dangerous, and in preventing the obstruc- 
tion of the parts which are affected, has been a 
long time since demonstrated ; and the point of 
practice which concerns those cases in which 
we ought especially to have recourse to them, 
is too solidly fixed, for it to be necessary to insist 
here, on the importance of their employment. 

It is above all, after surgical operations, that 
the practitioner ought to watch with extreme 
care, to prevent any inflammatory affection ca- 
pable of risking the lives of the sick. His 
attention ought to be directed with so much 
more perseverance towards this object, as he 
often introduces the instrument into the parts 
already irritated or inflamed, and, the operation 
being his work, he is, in a manner, immediately 
responsible for the results which it may bring 
on. " If surgeons, " says Broussais, " have ob- 



44 PHYSIOLOGICAL DOCTRINE, 

tained but little success from the operation of 
trephineing, it is, because after the. performance 
of the operation,, they have not combatted with 
sufficient energy, the irritation of the brain and 
its membranes, and because they have had re- 
course to revulsives on the intestines before the 
proper time : that is to say, before having suf- 
ficiently diminished the cerebral excitation, by 
local and general bleedings. If after the opera- 
tion of cutting for the stone, they have often to 
deplore the loss of the patient, it is because they 
have not attacked with sufficient energy, the 
cystitis, the peritonitis, and the gastro-enteritis 
consecutive to the incision of the bladder, and 
the extraction of the calculus." These reflec- 
tions are applicable to divisions of the articu- 
lations, those of the neck of the womb, the 
operations for empyema, paracentesis, strangu- 
lated hernia, and most of those which may be 
called the capital operations of surgery. " In a 
word," again adds Broussais, " if those opera- 
tions, in spite of the incontestable skilfulness of 
the French surgeons, are frequently followed by 
misfortune, it is because they do not pay suffi- 
cient attention to prevent the inflammations by 



APPLIED TO SURGERY. 45 

which they are succeeded, and because they do 
not use sufficient perseverance and vigour in 
the debilitating treatment, and in those sanguin- 
eous evacuations by which they should oppose 
them." 

For this reason then, as soon as, in spite of 
the rational employment of the means most 
strongly indicated, we see that the pain, the 
swelling, and redness are developed with force 
in the wounded parts, it is necessary to have re- 
course again to sanguineous evacuations. But 
at this time, general bleedings are less suitable 
than those which operate in the neighbourhood 
of the wound. The former act on the whole of 
the circulating system, and moderate its excite- 
ment; but they are only proper when the subject 
is strong aud plethoric, and when the pulse is 
full, large, and jerking : besides, they scarcely 
ever render it unnecessary to have recourse to 
local bleedings. The latter, in effect, produce 
their action directly on the irritated capillary 
system : by emptying and carrying off the 
blood which increased the stimulation, they 
keep the inflammation in proper bounds. M. 



46 PHYSIOLOGICAL DOCTRINE, 

Gama has justly given them the name of reg- 
ulators of local inflammations. 

To obtain all the good which can be derived 
from local bleedings, it is necessary to apply the 
leeches in the very place where the wound is 
situated, if the skin is not inflamed ; or in its 
neighbourhood and as near as possible, if the 
integuments are divided or irritated. It is im- 
portant, likewise, after a first application pro- 
portionate to the violence and extent of the 
disease, to repeat the employment of those 
animals, when the inflammation continues to 
progress. But then, instead of proceeding again 
with large numbers of leeches, it would be better 
to divide and apply them successively. In this 
manner, we keep, in the neighbourhood of the 
inflammation, a permanent afflux of blood, a 
sort of canal of derivation, which, in a little 
time, puts an end to the inflammation. M. 
Demours employs local bleedings in this man- 
ner, with the greatest success, in cases of oph- 
thalmia, or other inflammations of the eye and 
its accessary parts. I have several times corn- 
batted in the same manner, and always suc- 
cessfully, gastrites, cystites, and inflammations 



APPLIED TO SURGERY. 47 

of the joints following wounds in the neigh- 
bourhood of these parts. One observation 
which it is important to have presented to the 
mind in employing this remedy, is, that the 
number of leeches which remain applied to the 
parts and whose bites constitute the canal of 
derivation, ought to be proportioned to the vio- 
lence, extent, and danger of the disease. Thus, 
in cases of ophthalmia, or whitlow, we may 
confine ourselves to keeping two or three leech- 
es around the eye, or upon the finger; the artic- 
ular inflammations, those of the encephalon, the 
bladder, or the peritoneum, often require that 
eight, ten, fifteen or twenty should remain. We 
commence, then, by applying the number which 
ought to remain, and, as one falls off, we re- 
place it by another. The duration of the appli- 
cation ought to be prolonged 'until the pain, the 
redness, and swelling are notably diminished. 
When it has come to this point, the draining, 
which continues for some time still by the bites, 
suffices ordinarily to accomplish the subsidence 
of the inflammation. I have often times prov- 
ed, that twenty, thirty, or forty leeches, applied 
in this manner, produce a great deal more ef- 



48 PHYSIOLOGICAL DOCTRINE, 

feet, than if we apply them at one time, or in 
two or three portions. 

To local bleedings, it is nece ssary to join the 
application of fomentations or emollient cata- 
plasms, baths, general and local, total absti- 
nence from all kinds of solid aliment, and even 
animal broths ; the use of acidulated drinks 
and mucilaginous lavements. It is rare, that 
a treatment thus combined, directed with pru- 
dence and perseverance, does not succeed. If, 
in the meanwhile, the irritation does not yield, 
it becomes necessary to join to local anti-phlo- 
gistics, the use of revulsives, applied, either on 
the gastro-intestinal mucous membrane, or on 
the integuments, by means either of purgatives 
continued in small doses, or vesicatories placed 
in the neighbourhood of the seat of the dis- 
ease. But, it should not be forgotten, that 
these means should only be used, when the 
sanguineous evacuations have produced a salu- 
tary disengorgement, and a great diminution in 
the violence of the inflammation. Previous to 
this, far from being useful, the stimulation which 
they produce on the other organs, augments 
sympathetically, that which we wish to combat. 



APPLIED TO SURGERY. 49 

In a. word, making an abstraction of the cause 
of the disease and the physical alteration of the 
tissues, it is necessary to act in the treatment 
of acute surgical affections, as if there existed 
only one intense inflammation of the affected 
organs. 

Clinical observation proves every day more 
strongly, that local bleedings constitute the 
most certain method of combatting inflamma- 
tions. The acute phlegmasia of the lungs, and 
the liver, are, perhaps, the only ones which make 
an exception to this rule, and for the treatment 
of which, general bleedings are more efficacious 
than the others.* But in all cases of affections 
of external parts of the body, it is to these last 
that we should have recourse. Among the sur- 

* This difference appears to me to arise from the fact, that the 
liver and lungs receive, independently of the blood which is carried 
to them by their proper and nutritive vessels, another quantity of 
this fluid which they are destined to receive and elaborate. Now, 
the abstraction of a part of the blood which ought to be modified 
by these organs, is the only means which we can possess of re- 
lieving their functions and procuring for them a kind of repose. 
The general bleeding acts then in such cases, less in diminishing 
directly the inflammation, than in rendering less considerable the 
labour which the lungs and liver are destined to execute in a given 
time. This circumstance is again exemplified but in a less degree, 
by the spleen and kidnies, parenchymatous organs, which, re- 
ceiving large arteries, have scarcely any direct communication 
with the exterior of the body. 



50 PHYSIOLOGICAL DOCTRINE, 

geons who have made, a use of this remedy, as 
successful as frequent, M. Janson, surgeon in 
chief to the Hotel-Dieu of Lyons, merits a dis- 
tinguished place. This practitioner, having ob- 
served that the veins which branch off from the 
inflamed parts, are almost always tumified and 
filled with more blood than in their ordinary state, 
has made it a practice to open those which are 
bordering upon the wounded or irritated parts. 
Are local bleedings of this kind as efficacious 
as those which we obtain by the application of 
leeches ? I do not think so ; but experience 
alone can determine positively this question. 
In all . cases, the opening of the veins near 
the inflamed organs presents great advantages. 
First, it can be executed without increasing, 
even momentarily, the local pain, as do some- 
times the leeches applied too near the seat of 
the disease. In the second place, they are not 
expensive, which is of great importance in hos- 
pitals, and we can perform them in all countries, 
and under all circumstances. In the army, 
above all, where one is often deprived of phar- 
maceutical resources, bleedings practised in this 
manner, constitute a precious remedy which 



APPLIED TO SURGERY. 51 

military surgeons can often make use of. Fi- 
nally, the opening of veins permits us to mea- 
sure exactly the quantity of blood evacuated : 
that which is always very difficult to do when 
we employ leeches. But, although the open- 
ing of veins which have their radicules in the 
irritated parts, acts directly on the capillary 
vessels of these parts, the depletion which they 
produce is, perhaps, too rapid, to produce effects 
as happy as the application of leeches. What- 
ever may arise from these conjectures, we ought 
to feel indebted to M. Janson for having fixed 
the attention of practitioners, on this method of 
performing local depletions. It is to be desired, 
that we could bring together promptly a suffi- 
cient number of comparative observations, to 
fix definitely their value. 

If there was any necessity to produce here 
new arguments in favour of the efficacy of a 
suitable anti-phlogistic treatment applicable to 
acute surgical affections, I would be only em- 
barrassed in the choice of observations neces- 
sary to be made. Why, for example, are the 
wounds penetrating the great ginglymoid artic- 
ulations, still fresh, considered as cases where 



52 PHYSIOLOGICAL DOCTfclNE, 

amputation ought to be necessarily performed ? 
Why were complete luxations with rupture of 
the ligaments, of the articulations of the knee, 
the elbow, and the leg with the foot, thought 
so dangerous, that most surgeons did not hesi- 
tate to sacrifice the parts of which they were 
the seat ? This fear exaggerated by dreadful 
accidents and inflammations often fatal, depen- 
ded, incontestably, on the little knowledge prac- 
titioners then had, of employing local bleedings 
with sufficient energy, to prevent or combat ef- 
ficiently, the acute phlegmasia which succeed 
the affections of which we speak* We have 
known for a long time, that absolute rest of the 
limbs, attention to not letting the air penetrate 
the synovial cavities, and emollient applications, 
are means very useful in all cases of wounds 
of the articulations. J. L. Petit has taught 
surgeons not to dread making extensive inci- 
sions about these parts. But, it would be 
necessary to add to these remedies, abundant 
and repeated local bleedings, without which 
they are ordinarily insufficient. Therefore, for 
some years since, they have made general use 
of this remedy: we can already reckon up a 



APPLIED TO SURGERY. 58 

sufficiently great number of examples of gun- 
shot and other wounds of the great articula- 
tions, which have been cured not only with a 
preservation of the parts, but still without the 
disturbances having proved of a very consider- 
able kind. I could cite as readily a great num- 
ber of counter-proofs, that is to say, observations 
where it may be seen that a forgetfulness of 
the precepts pointed out, has been followed 
by the most deplorable consequences. Among 
the facts of this kind which I possess, I shall 
confine myself to relating the following. A 
man entered, in the course of the year 1816, 
into a hospital ; he had received a wound from 
a sword, on the external and posterior part of 
his right knee. The external lateral ligament 
of the joint was divided ; and the capsule exten- 
ding open about two inches, the fibro- cartilage 
on that side could be seen, and likewise, the 
posterior partv of the external femoral condyle. 
The wounded person was young, vigorous, and 
of a sanguinous and nervous constitution. There 
was nothing in the wound, nevertheless, which 
announced that it must have n fatal termina- 
tion : there only existed at its borders a moder- 



54 PHYSIOLOGICAL DOCTRINE, 

ate separation, which disappeared by the flexion 
of (he leg ; there was no contusion, and the part 
was not yet the seat of any pain. The surgeon 
engaged in the service wished however to pro- 
ceed to amputate on the field ; but, hindered by 
the observations of some assistants, he placed 
the limb in a demi-flexed position, brought to- 
gether the lips of the wound, and bled from the 
arm. 

The first night and the day following, he was 
sufficiently easy. Towards the evening of the 
second day, lively and lancinating pains were 
manifested ; their intensity increased gradually, 
and very soon became insupportable. They 
extended, as by irradiation, from the point of 
the wound to the rest of the joint, and the 
patient being extremely agitated, had the pulse 
hard, frequent and firm. The surgeon in atten- 
dance applied three leeches around the knee. , 
A great quantity of blood flowed out by the 
bites, and it was favoured in its exit, by means 
of an emollient cataplasm. Scarcely was the 
local bleeding commenced, when the pain dis- 
appeared as by enchantment ; the patient be- 
came easy, and slept until morning. On the 



APPLIED TO SURGERY. 55 

night following the pains reappeared, but with 
less intensity than the night preceding, and as 
the application of the leeches was not renewed, 
they were very violent by the visit in the morn- 
ing. Some persons then proposed to have re- 
course again to local bleeding ; but the chief 
surgeon declared that he would temporize no 
longer ; adynamia appeared to him, must be the 
inevitable result of another sanguineous evacua- 
tion, and he decided that amputation be perform- 
ed immediately. It was endured with admirable 
sang-froid by the patient, and crowned with 
entire success. On examining the parts we 
did not find any notable redness in the cartila- 
ges, nor in the synovial membrane, nor in the 
fibrous tissues which strengthen the articula- 
tion. It appeared, that there was still, only 
a simple irritation in the parts, the afflux of 
the fluids had not yet commenced, or having 
been so feeble, that the section of the neighbor- 
ing vessels during the operation, was sufficient 
to dissipate the slight traces of the commence- 
ment of inflammatory action. 

This fact furnishes a new proof of the bane- 
ful influence, which that phantom adynamia 



56 PHYSIOLOGICAL DOCTRINE, 

exercised but a short time since, on surgical 
practice. In joining the preceding observation 
to many other analogous facts of which I have 
been a witness, I cannot but vindicate the belief 
that anti-phlogistic means, more active, and con- 
tinued with more perseverance, might have pre- 
served to the patient, the limb of which he was 
deprived. 

Local bleedings are useful in a great number 
of subjects, to insure the success of surgical 
proceedings. Thus, for example, after the ex- 
act reunion of the lips of a wound, if the local 
inflammation is too intense, we see that adhe- 
sion cannot take place, and suppuration renders 
useless all the efforts employed to promote it. 
In these cases, the application of leeches near 
the tumified and painful borders of the divi- 
sion, removes, as M. Gama has observed, this 
excess of irritation, and safely maintains the 
inflammation within the limits by which it pro- 
duces the agglutination of the contiguous parts. 
After amputations we often see the stump be- 
come the seat of a vast inflammatory swelling ; 
it may be by the action alone of the cutting 
instrument, or it may be in consequence of the 



APPLIED TO SURGERY. 57 

tjdng of some nervous filaments, or by the too 
sudden interruption of the blood in the vessels 
which give rise to the arterial trunk above 
the point of the ligature. On these occa- 
sions, after one or two general bleedings, noth- 
ing can serve the place of leeches : applied on 
the tumified part, they prevent certainly, those 
extensive effusions, which dissect, in a manner, 
and separate the muscles from each other; those 
denudations of bone which give rise to those 
interminable suppurations, and retard the cure 
of patients for many months ; those conical 
forms of stumps which render the cicatrices so 
easily torn, and prevent the application of me- 
chanical means, by the aid of which they can 
serve the place of lost limbs. Finally, when, 
after a ligature of the large arterial trunks, we 
see the blood penetrate the collateral branches 
with too much force, distend and irritate the 
capillary vessels which terminate them, and 
provoke the augmentation of the temperature of 
the superior parts of the limb, whilst the inferior 
parts remain cold, the application of leeches 
on the first, at the same time that we envelop 
the latter with warm satchels, contribute very 
8 



58 PHYSIOLOGICAL DOCTRINE, 

much to regulate the circulatory movement, and 
to insure the preservation of the parts. 

The use of antiphlogistic means and local 
bleedings in the treatment of most of the acute 
affections of which the exterior parts of the body 
may be the seat, actually render more rare than 
formerly, the occasions in which surgical opera- 
tions are indispensable. By its union with a me- 
dical treatment more rational, and more physio- 
logical, surgery is now rendered more conserva- 
tive. Wounds of fire arms, extensive and deep 
contusions, are actually cured without its being 
so often necessary as was believed by our 
predecessors, to retrench the diseased parts. 
After wounds of the head, the application of 
leeches to the throat, the back of the neck, and 
the temples, or what is still better, to the in- 
jured parts themselves, supply the place frequent- 
ly, of the operation of the trephine. This reme- 
dy, aided by general bleedings, diet, and acidu- 
lated drinks, is more useful, especially in the first 
periods of cerebral irritation, than the detergent 
emetic, the advantages and efficacy of which, 
Desault so much exagerated to himself. The 



APPLIED TO SURGERY. 59 

same observation can be made in those cases 
of wounds of the chest or of the abdomen. 
When we arrive at the second part of this work, 
we shall still see, in treating chronic diseases of 
the exterior parts of the body, that, under a crowd 
of circumstances, local bleedings can render un- 
necessary the most serious operations of surgery. 
In effect, scrofulous degeneracies, cancers,eating 
ulcers, white swellings, sarcoceles, and a multi- 
tude of other affections considered as incurable 
otherwise than by steel or fire, have been recent- 
ly cured by a general and local antiphlogistic 
treatment, proportioned to the extent of the dis- 
ease and the strength of the patients.* These 
conquests of surgery during these latter years, are 
as glorious, and perhaps more profitable to hu- 
manity, than were the numerous improvements 
in operating and surgical instruments, during the 
latter end of the last century. 

One of the most remarkable results of the ap- 
plication of the principles of physiological me- 
dicine to surgery, is, that the practitioners who 

- — — - ■ — _ _ _ . _ 

* For some interesting remarks and cases by M. Foucart, 
with regard to the utility of antiphlogistics in certain surgical affec- 
tions, see the Annates de la Medecine Physiologique, tome 17^.50 
—Trans. 



60 PHYSIOLOGICAL DOCTRINE, 

have adopted the basis of the new doctrine, have 
scarcely any more occasion to observe those e- 
normous inflammatory swellings which were for- 
merly so frequent, and which, disorganizing the 
parts,rendered amputations necessary, when they 
did not cause the patients to die. These results are 
analogous to those which we have obtained, by 
the new treatment of gastro-enterites, affections 
almost all of which terminate unfavourably, and 
which do not arrive, but amongst a small number 
of patients,to that degree of intensity which gives 
place to the phenomena of adynamia and ataxia, 
The great quantity of leeches that is applied with 
so much success in visceral inflammations, ought 
to encourage surgeons not to be sparing of the 
number with which they cover the external irri- 
tated parts. A local bleeding not sufficiently a- 
bundant, is frequently more injurious than useful, 
as it determines towards the region of which it 
is the seat, a congestion more strong than that 
which it was destined to counteract. It is ne- 
cessary then to act with energy, and forty or fifty 
leeches employed at a time, are, in # general, 
necessary in all those cases of intense ir- 
ritations; it is even often indispensable to have 



APPLIED TO SURGERY. 61 

recourse to them several times, when the inflam- 
mation is obstinate. 

These general therapeutical principles are ap- 
plicable to inflammations of external parts of the 
body, such as phlegmon, erysipelas, furunculus, 
and anthrax, as well as to those irritations pro- 
duced by wounds, contusions, fractures, etc. It 
must not be forgotten, however, that, in furun- 
cle, and anthrax, the cellular tissue having been 
deadened by strangulation, it is necessary to 
have recourse to incisions, which shorten and 
facilitate the work of nature, by releasing the 
parts and giving issue to the matter. These in- 
cisions, made crucial or starlike, and prolonged 
to the limits of the tumour, constitute the means 
the most efficacious in putting a stop to the pro- 
gress of anthrax. In cases of carbuncle and ma- 
lignant pustule, it is necessary to cauterize the 
gangrenous parts and those which are more im- 
mediately threatened with mortification ; in fine, 
to destroy the disease, and to excite in the neigh- 
bouring tissues, a more salutary inflammation, 
which preserves them from destruction. Except 
these cases, gangrene being the result of the ex- 
cess of local inflammation, judicious practition- 



62 PHYSIOLOGICAL DOCTRINE, 

ers will take good care, not to endeavour to pre- 
vent or limit it by the application of topical irri- 
tants. These means are only proper to increase 
the intensity of the inflammation in the still liv- 
ing parts, and to hasten the period and progress 
of their mortification. It is by the aid of anti- 
phlogistics that we may prevent most certainly 
the manifestation and progress of external gan- 
grenes, by keeping the inflammations that de- 
termine them, within just bounds. The adage, 
which has had, in the practice of surgery, as well 
as in medicine, the most pernicious consequen- 
ces, is thought to be the following : " When," 
says a modern writer, more remarkable for the 
brilliance of his style than for the profoundness 
and justness of his opinions ; " when prostration 
of strength, complicates an inflammation, whate- 
ver be its seat,do not fear to augment it by the use 
of tonics."* It is at this day perfectly demon- 
strated, that, this prostration depends, almost al- 
ways, on the excess of local inflammation, or the 
sympathetic inflammation of the stomach and 
intestines,t and that the above axiom, independ- 

* Nosographie chirurgicale, torn. 1, page 204, 5e. edit, 
f This is one of the most important truths of Physiological 
Medicine ; but it is overlooked by physicians and surgeons edu- 



APPLIED TO SURGERY. 63 

ently of that which is absurd in theory, would be 
very dangerous if it were strictly followed in 
practice. 

cated in the principles of the ancient doctrines. They do not 
know that an exaltation or diminution of the vitality of the organs 
cannot be general and uniform, and that the exaltation of one or 
several organic systems, or of one or several apparatuses, always 
produces languor of some other system or apparatus. Thus, 
when the gastro-intestinal mucous membrane is super-excited, 
muscular innervation diminishes. When the locomotive appara- 
tus is in a violently convulsive state, the action is deficient in the 
vascular system; the secretions are suspended ; nutrition languish- 
es; and the heart directs the circulation of the blood in a defective 
manner. By giving stimulants, we aggravate the local inflammation, 
and by augmenting this inflammation, increase the debility which 
it caused, and which we wish to remedy. It is to Broussais that 
we are indebted for exposing such errors, and taking correct 
views of pathology. — Trans. 



64 PHYSIOLOGICAL DOCTRINE, 

Chapter III. 

Sympathetic phenomena determined by acute 
surgical lesions. 

When ever an active irritation is developed on 
the external part of the body, it determines sym- 
pathetically a more or less considerable distur- 
bance in the functions of the principal viscera of 
the economy. Fever is developed. When the 
febrile action is simple, it presents to the obser- 
ver the characters of that which we call inflam- 
matory fever; and when it succeeds to wounds 
or other external injuries, we give to it the name 
of traumatic fever. In those subjects in whom 
this fever exists at the same time with an abund- 
ant bilious, or mucous secretion, and among those 
in whom either great debility of the animal or- 
ganization or a perversion of the action of the 
nervous system follows, practitioners say, ordina- 
rily, that it has degenerated, or that it is con- 
verted into a bilious, mucous, adynamic, or a- 
taxic fever. Let us examine under what cir- 
cumstances, and by what mechanism, these pre- 
tended degeneracies are brought about. 



APPLIED TO SURGERY. 65 

The viscera are not gll disposed to receive 
with equal intensity, the sympathetic irradia- 
tions produced by affections of external parts 
of the body. The brain, the stomach, and the 
heart, appear to form in the midst of the living 
organization, the central points towards which 
converge all the unusual vital actions, deter- 
mined by the irritations of other organs. The 
first of these viscera receives, through means of 
the nerves, the sympathetic impression produc- 
ed by the part irritated, and reflects it through- 
out all the divisions of the nervous system, and 
above all, towards the epigastric centre, and 
towards the heart. Then the signs of gastro- 
enteric and acceleration of the pulse are mani- 
fested, and the febrile action commences. But, 
if upon the invasion of the disease, all the organs 
are in their normal state, and the external affec- 
tion be moderated, the febrile excitation is not 
violent, and does not present any danger. We 
observe the following phenomena : strong, full, 
and frequent pulsations of the arteries, moderate 
thirst, want of appetite, disgust for animal sub- 
stances, desire to take cold and acidulated drinks, 
redness of the end and borders ©f the tongue? 
9 



66 PHYSIOLOGICAL DOCTRINE, 

the middle part of which, is moist and whiteish, 
augmented heat and halitus of the skin, urine 
at first scanty, limpid and colourless, afterwards 
sedimentitious and abundant. Towards the sec- 
ond, third, or fourth day, all these phenome- 
na diminish, at the same time that the suppura- 
tion manifests itself in the wound, and the in- 
tense imflammation of the parts affected disap- 
pears. 

Such is the ordinary and most advantageous 
progress of diseases. But if, at the period that 
the symtomatic fever develops itself, the visce- 
ra have the excitation which is due to them, 
they are subject to the influence of other causes 
of irritation, or if they are already more or less 
strongly irritated, the phenomena above men- 
tioned, acquire an increase of intensity, or even 
other affections are manifested. Let us suppose, 
for example, that a bilious person, in whom the 
gastro-hepatic apparatus is very irritable, is 
wounded; is it not evident that the gastro-enter- 
ite which he experiences at the period of the 
inflammation of the injured parts, will be more 
intense than in a man furnished with a different 
organization ? In his case, the irritation of the 



APPLIED TO SURGERY. 67 

stomach is complicated with an abundant bili- 
ous secretion, nausea, vomiting of greenish and 
bitter stuff, bilious diarrhoea, a yellow tint spread 
over the whole surface of the body, in a word, 
all the si^ns common to bilious fevers. Let the 
wounded person of whom we speak, be, on the 
contrary, disposed to mucous secretion ; let him 
have a great quantity of saburral matter in 
the alimentary courses ; will it be surprising 
that these circumstances determine great modi- 
fications in the symtoms of gastro-enterite, and 
produce all the phenomena of mucous fevers ? 
If the external inflammation is very considera- 
ble, or if the gastro-enterite having had at first 
one of the above forms, has been opposed by 
vomits, purgatives, and bitters which have ex- 
asperated it, it may happen that the inflamma- 
tion of the stomach and the intestines will ac- 
quire a still higher degree of violence, and 
determine the symptoms of adynamic fever. 
Finally, if it is a nervous subject, very irritable, 
and endowed with great cerebral susceptibility, 
we will observe the brain or its membranes, 
participating in the irritation of the digestive 
canal, give place to the aberrations of sensibility, 



68 PHYSIOLOGICAL DOCTRINE, 

determine convulsions, or occasion delirium, 
sometimes cheerful, at other times melancholy, 
or furious ; in a word, excite those perversions 
of actions which characterize the ataxic state. 
Thus it is, that, the principles or the causes 
of diseases remaining the same, the attentive 
observer sees those last multiply themselves, if 
we may use the expression, and assume a thou- 
sand variety of forms, following the nature and 
infinite modifications of individual constitutions. 
One general rule, the consideration of which 
is of the highest importance in the subject which 
we now occupy, is that the intensity of symp- 
tomatic fevers produced by external affections, is 
constantly in relation with the force and extent 
of those affections, and likewise with the sen- 
sibility of the parts of which they are the seat. 
For this reason, after simple fractures and un- 
complicated wounds of the soft parts, the febrile 
excitation is but slight and transient : it acquires 
on the contrary very considerable force and be- 
comes dangerous, when the limbs are broken 
by direct causes, or disorganized by projectiles 
put in motion by the powder of a cannon. Fi- 
nally, an intense inflammation of the extremity 



APPLIED TO SURGERY. 69 

of the finger causes more suffering, and deter- 
mines sympathetic phenomena more multiplied 
and more serious, than that of a portion, even 
* more extended, of the sub-cutaneoif! cellular 
tissue of any other part. 

It is not alone the different shades of gastro- 
enterite and cerebral super-excitation that may 
follow irritations produced by affections of ex- 
ternal parts of the body. Whenever the wound- 
ed subjects have an organ more sensible or more 
irritable than the rest, this organ is eminently 
disposed to become inflamed at the period when 
the traumatic fever ought to appear. This fact, 
which is incontestable, depends upon this : the 
irritated organs form accidental centres of ac- 
tion in the economy, towards which converge 
all the sympathetic movements. 

Clinical observation has demonstrated, for ex- 
ample, that pneumonias, pleurisies, hepatites, ne- 
phrites, cystites, and likewise arthrites, are man- 
ifested on account of the most simple wounds, 
in those subjects in whom the pleura, lungs, 
liver, kidneys, bladder, or the articulations, were 
already irritated or disposed to inflame. It is a 
law of the living economy, that the inflamed 



70 PHYSIOLOGICAL DOCTRINE, 

parts constitute, as it were, new foci of vitality, 
which change absolutely, the order of sympa- 
thies. In the normal state, the organs have 
relations between themselves determined by the 
degree of susceptibility of each of them, and the 
stomach is above all, that which is united to the 
rest of the body, by the closest sympathies. But, 
in the pathological state, when some other part 
is endowed with an excess of vitality, it be- 
comes, for this reason, the most sensible point 
of the organization; all the excitations converge 
towards it, and its acute inflammation may be 
the result of the disturbance excited by any 
other inflammation. 

The inflammations of which we speak, and 
the appearance of which, the wounds determine 
sympathetically in other organs than the diges- 
tive canal, do not, properly speaking, succeed 
gastro-enterite ; they precede it, or are develop- 
ed at the same time, and give to it an increase 
of force. By it, the fever becomes more violent; 
and the economy presenting more multiplied 
points of phlogosis and irritation, is thereby 
threatened with an augmentation of the danger 
which menaces it. 



APPLIED TO SURGERY. 71 

These considerations are of the highest im- 
portance in medico-chirurgical theory and prac- 
tice ; they serve to explain a multitude of morbid 
phenomena, and furnish the basis of the prophy- 
lactic, or curative treatment of a great number 
of internal affections with which wounds are 
complicated. 



72 PHYSIOLOGICAL DOCTRINE, 

Chapter IV. 

Treatment of internal irritations which com- 
plicate surgical affections. 

The curative indications presented by internal 
diseases which may complicate the acute affec- 
tions of external parts of the body, are easily 
determined, after the physiological and patho- 
logical details into which I have entered. They 
consist 1st, in rendering as feeble as possible, 
the local inflammation which is the primitive 
cause of all the ailments : 2nd, in combating 
the dispositions which patients often present, 
either to violent irritation of the digestive or- 
gans, or to inflammation of some other viscera : 
3d, in removing from the wounded, all those 
causes of inflammation which are capable eith- 
er, of rendering more intense the sympathetic 
affections with which they are threatened, or of 
developing in them other inflammations : 4th, 
lastly, in counteracting affections, the develop- 
ment of which it was impossible to prevent. 

1st. To diminish the violence of local in- 
flammation. The remedy the most sure and 



APPLIED TO SURGERY. 78 

most efficacious to render the traumatic fever 
less lively, and to oppose the manifestation of 
intense sympathetic inflammations in wounded 
persons, consists in making use of the anti-phlo- 
gistic treatment, the advantages of which I have 
already spoken. Mild dressings, a suitable po- 
sition of the part affected, the application of top- 
ical emollients, and above all, local and general 
bleedings : these are the means, the employment 
of which we wish most to insist upon. We still 
recollect the observation of our excellent Pare, 
who, not being able to cauterize all the patients 
who had received gun-shot wounds, found those 
to whom boiling oil had been applied, a prey to 
horrible pains and agitated by veiy intense fe- 
vers; whilst the others, for the fate of whom he 
had become very anxious, were easy and with- 
out fever. I have been many times assured, of 
late, that it is always possible to arrest the pro- 
gress of traumatic fever, or even to prevent its 
development, by covering the affected parts with 
leeches as soon as the inflammatory congestion 
begins to take place, and by submitting the 
wounded to a strict diet, such as the use of 
10 



74 PHYSIOLOGICAL DOCTRINE? 

emollient drinks and other means of the same 
kind.* I have had the good fortune, for exam- 
ple, to remove, in a few hours, an incipient 
whitlow, likewise the febrile agitation which 
accompanied it, by applying a few leeches on 
the finger of which it was the seat. 

When the fever appears to be kept up exclu- 
sively by an intense local inflammation, it is 
frequently possible to remedy^ it by means of 
operations which stop the latter promptly. There 
is no surgeon who has not observed that the in- 
cision of the irritated and strangulated parts, is 
almost always followed by the prompt disap- 
pearance of the pain, the acceleration of the 
pulse, and the other circumstances which ac- 
company it. These incisions and local bleed- 
ings are still the means the most efficacious 
which we are able to oppose to those acute in- 



* M.Treille has related in the Annates de la Medecine Physio- 
logique, seven cases of amputation of the limbs and breasts, in 
which complete cicatrization was effected, without the patients 
having experienced any febrile action. By keeping the inflamma- 
tion within the limits of the wound, traumatic fever may almost 
always be prevented. This has been taught by Broussais, and 
numbers of his followers have proclaimed the same truth : it has 
become one of the fundamental axioms of French surgery. For~ 
merly, this fever was maintained to be a necessary phenomenon 
and effect of extensive wounds. — Trans. 



APPLIED TO SURGERY, 75 

llammations in which the sub-aponeurotic cel- 
lular tissue of the skull is strongly compressed, 
and which often make such extensive and dang- 
erous ravages. In consequence of wounds of 
fire-arms, the inflammation is, among a great 
many subjects, the result of the openings not 
having been sufficiently enlarged, or from the 
course of the wound concealing foreign bodies. 
These circumstances being known, suitable 
incisions ought to be immediately practised : it 
is never too late to have recourse to them. 
At Dresden, I could observe a great number 
of patients in whom, the wounds penetrating 
through the limbs, had not been enlarged by 
incisions on the spot, either because they did 
not consider it necessary to perform this opera- 
tion, or because the women or other ignorant 
persons had applied the first dressings. About 
the fifth or sixth day of their wounds, these un- 
fortunates were a prey to horrible pains; extreme 
agitation, and violent fever tormented them ; 
their limbs, swelled, heated, and bent, could not 
support the slightest pressure. The courses of 
the wounds were obliterated by the swelling of 
the flesh. Notwithstanding the violence of 



76 PHYSIOLOGICAL DOCTRINE, 

these inflammatory accidents and the local irri- 
tation, notwithstanding the length of time that 
had elapsed from the invasion of the disease, I 
did not hesitate to practise extensive incisions 
among these soldiers, proper to give entire free- 
dom to the inflamed and compressed tissues. 
The balls which were enclosed in several of 
the wounds, were at the same time extracted. 
Not only did no accident follow these opera- 
tions, which were however more painful than 
those which we practice on the sound tissues, 
but amongst all those who endured them, the 
fever subsided, the agitation was calmed, and 
after three days, the evacuation march, which 
those men hindered, became disencumbered by 
their departure. We should not hesitate any 
longer if the inflammation* is exasperated by 
splinters detached from the bones. 

When, in consequence of fractures, an intense 
inflammation invades the soft parts, it is gener- 
ally advised to put off the reduction until this 
accident is removed ; but the most powerful 
Cause of this inflammation consists evidently in 
the asperities of the bones, which lacerate the 
cellular tissue, the muscles, and sometimes the 



APPLIED TO SURGERY. 77 

neighbouring nerves. To delay, is to allow this 
permanent stimulation the means of acquir- 
ing the highest degree of violence and of dis- 
organizing the parts. It is then necessary to 
proceed immediately to the reduction. The 
bones being placed in apposition and maintain- 
ed in this situation, the local tumefaction di- 
minishes very soon, and at last is completely 
removed. This is the only practice that is rea- 
sonable, and worthy of an enlightened surgery: 
it has been for a long time since followed by 
Dupuytren. 

2nd. To combat the previous irritations of 
the viscera. Celebrated surgeons, and amongst 
others the illustrious Lamartiniere, have estab- 
lished, especially in the army, the custom of 
vomiting almost all the men receiving wounds 
from fire-arms, before the development of trau- 
matic fever. This method has found partisans 
even in our day, notwithstanding the immense 
progress of pathological physiology. The emet- 
ic, say the followers of Lamartiniere, has the 
advantage of evacuating the first passages and 
of preventing the appearance of gastric and 
intestinal disorder so frequent among soldiers. 



78 PHYSIOLOGICAL DOCTRINE, 

These practitioners think likewise, by this vom- 
iting medication, to oppose efficaciously, the 
manifestation of supposed bilious, mucous, or 
putrid fevers, to which the wounded are, accord- 
ing to them, much exposed.* 

It is true, that soldiers during a campaign, 
submitted to great fatigue, to the use of bad 
food, abandoned to those excesses in eating 
which not happening often, are so much more 
dangerous as they alternate with painful priva- 
tions; it is true, I say, that men exposed to all 
these causes of disease, have, almost constantly, 
the digestive organs, either irritated, or disposed 
to contract serious inflammations, at the period 
when their wounds determine the development 
of traumatic fever. But nothing authorizes the 
abuse, nevertheless, which certain persons make 
of emetics and purgatives. It is sufficient to 
examine soldiers having wounds from fire-arms, 
to see that this baneful and perturbating prac- 
tice ought only to be employed with extreme 

* See : Richerand, Nosographie chirurgicale, 1, p. 257. 
Boyer, Traite des maladies chirurgicales et des operations qui 
leur conviennent, torn. 1, p. 390. 



APPLIED TO SURGERY. 79 

reserve, and can only be suitable among a very 
small number of them. 

Among those men who are received into an 
army on the march, there are some who, for a 
long time, have made use of raw, indigestible 
food, little nourishing, and furnishing a great 
deal of excrementitious materials, such as fari- 
naceous pot-herbs, unripe fruits, the remains of 
vegitables, etc. These men have ordinarily a 
cold skin, the pulse feeble and tranquil, the 
tongue covered with a thick, whitish, mucous 
coat, without redness at its point or its sides; 
the epigastrium is not painful ; the belly, large 
and clammy, seems to be filled with stereorace- 
ous materials; finally, there is no appetite, slight 
thirst, and a mucous diarrhoea often exists. The 
wounded who present this aggregate of phe- 
nomena have the digestive canal obstructed by 
sabburral materials, which, produced in a great 
measure by the continued excitation of the mu- 
cous membrane, irritate it in their turn, and hin- 
der the exercise of its functions. Under ordinary 
circumstances, this indisposition will yield to 
diet, and the use of cooling and gently aperi- 
ent drinks ; but with the wounded, there per- 



80 PHYSIOLOGICAL DOCTRINE, 

haps, would be an inconvenience in allowing 
the traumatic gastro-intestinal irritation to de- 
velop itself, whilst the mucous membrane of the 
digestive canal is in contact with foreign sub- 
stances, the alteration of which, will not fail to 
add to the violence of the inflammation; and 
as the period when this inflammation ought to 
take place is very near, it is important to act 
promptly, that is to say, on the day or at farth- 
est the day after the wound. Emetics will fre- 
quently answer for such persons; but we ought 
promptly to succeed them by soothing drinks, 
to remove the stimulation which they must pro- 
duce. By the aid of these means we very soon 
see the appetite restored, and the dejected forces 
repaired ; and when traumatic fever is develop- 
ed in its turn, it is moderated, and exempt from 
all complication. 

It should not be forgotten, that, for it to be 
advantageous, the emetic ought to be adminis- 
tered in the first twenty-four or thirty-six hours 
after the wound. As much as this practice may 
be advantageous in the patients above mention- 
ed^ would be as little suitable if delayed a 
longer time. It would be better, after the sec- 



APPLIED TO SURGERY. 81 

ond day, to confine them to an expectant med- 
icine, and to insist on cooling drinks and laxa- 
tive lavements, than to expose them to a return 
of the fever during the disturbance produced by 
the emetics, and whilst the stomach still feels 
the stimulation which they have produced. It 
is useless, no doubt, to add, that this method 
never answers when the internal viscera are at 
the same time affected by wounds. 

It is observed, in the army, that the greatest 
number of wounded, present other phenomena 
than those which we have just mentioned. 
These men have the tongue red at its point 
and at its sides; the pulse frequent, quick, and 
firm; the skin dry, harsh, and burning; the ep- 
igastrium painful; the right hypochondrium of- 
ten swollen; and the alvine evacuations rare. 
They manifest a very striking aversion to all 
animal substances and alcoholic drinks; the 
thirst is intense, and they have a strong desire 
for acidulated liquids ; there exists frequently, 
nausea and bilious vomiting. These patients 
can never be vomited without danger. Their 
stomachs are, in fact, the seat of an intense ir- 
ritation, participated in, by the duodenum and 
11 



82 PHYSIOLOGICAL DOCTRINE, 

liver. The digestive mucous membrane is al- 
ready, perhaps, in a state of violent inflamma- 
tion, and evacuants exasperate certainly, all the 
symptoms. Bleedings on the epigastrium, an 
entire abstinence from all solid aliment, cool- 
ing and acidulated drinks, emollient clysters, 
and baths, are the most suitable means of treat- 
ment which we can employ. These medications 
have the effect of mitigating the gastric irriga- 
tion, likewise that of the duodenum, and, as a 
necessary consequence, the super-excitation of 
the liver, in such a manner, that at the period 
of the development of the traumatic fever, these 
organs are restored to their normal state. 

The maladies of which I have spoken in the 
first place, are sometimes quite numerous in cold, 
humid, and marshy countries, during the winter 
campaigns, and after long and difficult retreats. 
We have very seldom encountered them in 
hot, dry, and elevated countries, or when the 
war was carried on in the summer, and when 
the army, abundantly supplied with provisions, 
marched forward, and when victory crowned 
their enterprises. In the first case, the physical 
and the moral soldier were equally dejected; in 



APPLIED TO SURGERY. 83 

the other, all contributed to give to the organs 
extraordinary energy. 

Lastly, whenever men, having received seri- 
ous wounds, are not only indisposod, but already 
diseased, and affected with gastro-intestinal or 
other very violent irritations, it is necessary to 
employ the most energetic means, in order to 
remove promptly such dangerous complications. 
The most active anti-phlogistic treatment ought 
to be then constantly put in use. If the stom- 
ach and intestines are the seat of inflammation, 
general bleedings, and above all, leeches to the 
epigastrium, and emollient fomentations on the 
abdomen, should be added to the ordinary means. 
If the lungs, pleura, kidnies, or the other organs 
be painful and inflamed, it is towards the re- 
gions which they occupy, that we ought to di- 
rect both the local bleedings and topical emolli- 
ents. 

3d. To remove from the wounded all those 
causes capable of provoking in them, internal 
inflammations. We fulfil this indication by 
prescribing the rigorous execution of the pre- 
cepts of hygiene. Thus, the wounded ought to 
be placed in buildings conveniently situated; 



84 PHYSIOLOGICAL DOCTRINE, 

the wards in which they are put together, sufrl* 
ciently elevated and large for the number of 
men which they contain, ought to be pierced 
by windows on the opposite walls, and furnish- 
ed with ventilators : in this manner the atmost- 
phere can be easily and frequently renewed. A 
simple alimentation, wholesome, proportioned to 
the state of the digestive organs, to the intensity 
of the affections, and the development of the 
forces, maintaining a sufficient nutrition with- 
out disturbing the exercise of the organic move- 
ments. It is important to preserve the wounded 
from all too intense passion, and especially from 
sad impressions. The proper dressings, and in 
which we employ only bleached linen and tow, 
without odour, and not damaged, preserve the 
good condition of the wounds, and favour their 
cicatrization. Finally, a small number of med- 
icaments appropriated to different internal and 
external affections which often are manifested, 
are the agents which complete the series of re- 
medies, the employment of which, the wound- 
ed most ordinarily require. Like nature, medi- 
cine ought to be simple, either in its instruments, 
or in its proceedings, and able to originate a 



* 



APPLIED TO SURGERY. 85 

multitude of happy results, out of a very small 
number of divers actions. Experience has prov- 
ed, besides, that during the latter campaigns, 
when the doctrine of Brown had a great num- 
ber of partisans among the military officers of 
health,* that the hospitals deprived of emetics, 
of bark, and that crowd of irritating substances 
which has been so prodigally used; experience, 
I say, has proved, that these establishments not 
being able to furnish any thing but water, bread, 
wine, and broth, lost fewer of the wounded, than 
those where an assemblage of the greatest trea- 
sures of pharmacy might be found: a new proof, 
both of the power of hygienic means, and the 
abuse which they have made of excitants and 
tonics, in surgery as well as in medicine. 

4th. To combat the internal affections which 
complicate external injuries, when we have not 
been able to prevent their development. Not- 
withstanding the employment of the means 
which have been mentioned above, it happens 



* Officiers de sante. — This is a term applied to those persons 
whose duty, according to the reporters of the law, is the superin- 
tendance of such slight diseases as do not require the advice of the 
physician or surgeon. Their rank answers somewhat to that of 
surgeon apothecary in London. — Trans. 



86 PHYSIOLOGICAL DOCTRINE, 

sometimes that the sympathetic inflammations 
produced by external affections, progress, and 
expose the lives of the sick. This result takes 
place, either because the local inflammation 
which succeeded the wound, being very vio- 
lent, reacts with a great deal of force on the 
viscera, or because the inflammation of these 
last, has acquired a very high degree of inten- 
sity, from a predisposition of the subject, or by 
the action of foreign irritating causes. 

In the first case, it is necessary to insist on 
the local anti-phlogistic treatment, and to en- 
deavour in the end to combat the permanent 
causes of irritation which the part effected may 
contain. 

In the second, the remedies against gastro- 
enterics and the other inflammations which 
are often joined to them, ought to be continued. 

It is a general rule in pathology, that all sym- 
pathetic irritations, when they are violent, and 
when they do not yield to means employed to 
moderate the affection to which they have given 
birth, ought to be considered and treated as if 
they were primitive. Experience and reason 
accord to justify this maxim. It becomes ne- 



APPLIED TO SURGERY. 87 

.eessary then, in all cases where the gastro -en- 
tente is intense after the infliction of a wound, 
to direct against it all the effbrls of art. We 
ought to act in the same manner when other 
important organs are the seat of the inflamma- 
tion. 

When, notwithstanding the employment of 
this method of treatment judiciously directed, 
the phenomena of adynamic fever are manifes- 
ted, they indicate the prolongation and exasper- 
ration of the gastro-enterite. If the bleedings 
on the epigastrium have been sufficiently abun- 
dant and often, it is proper to exercise a power- 
ful revulsion on the limbs : strong sinapisms to 
the feet, legs, and knees; frictions with very hot 
camphorated vinegar on the integuments; Span- 
ish flies, with ammoniacal ointment, rubbed 
about the inner surface of the thighs, are the 
most active and most efficacious means which 
we can join to an anti-phlogistic treatment. 
The pulse and skin ought, nevertheless, to serve 
as a guide to the practitioner; as long as the 
first is hard and frequent, and the other presents 
a sharp and burning heat, it is necessary to in- 
sist on emollient medications; but when the pul- 



88 PHYSIOLOGICAL DOCTRINE, 

sations diminish and become less quick, at the 
same time that the integuments loose their heat 
and the muscular forces disappear, the time 
when we should have recourse to* revulsives 
has arrived, and we may emplpy with advan- 
tage, the tincture of bark, or other excitants to 
the exterior of the body. 

The phenomena of ataxic fever may be de- 
veloped in wounded persons, as well as in oth- 
er patients, in two almost opposite manners. 
Among the greatest number of subjects, the 
gastro-enterite, sympathetically produced by an 
external injury, becomes very intense; it reacts 
then with force on the encephalon, and finding 
this organ already disposed to become the seat 
of a violent excitation, it irritates, and deter- 
mines derangements more or less considerable 
in its functions. At other times, on the contra- 
ry, the sympathetic action, exercised by an ex- 
ternal affection on the viscera, seems to affect at 
first, especially the brain, and to extend after- 
wards to the digestive canal, because of the 
powerful influence which the encephalon exer- 
cises over this organ. In the first case, the 
cerebral irritation may be considered as a tern- 



APPLIED TO SURGERY. 89 

ary affection, as it is the result of the gastro-en- 
terite, produced by the wound itself; in the oth- 
er, the inflammation of the stomach and the 
intestines occupies, on the contrary, only a third 
place, for it succeeds to the inflammation which 
the external affection has determined in the en- 
cephalon or its membranes. These distinctions 
are not simply speculative ; they have facts for 
their base, and should be borne in mind in prac- 
tice. The first of these varieties of the disease 
is recognised by the redness of the tongue, the 
d-ryness of the skin, the thirst, etc., preceding 
the appearance of disturbed ideas, irregular 
movements of the pulse, convulsions and other 
affections of the same kind. The second is 
characterized, by the reverse, because the phe- 
nomena depending on cerebral excitation, are 
manifested before those of gastro-enterite : these 
phenomena have moreover a violence more 
considerable than would seem to comport with 
the feeble intensity of this last affection. But, 
whether the disease firsts manifests itself by the 
stomach or by the brain, the observation of sub- 
jects whilst alive, and the examination of bodies 
after death, have proved that these two viscera 
12 



90 PHYSIOLOGICAL DOCTRINE, 

are effected when ever it has acquired its entire 
development. In taking for a model the de- 
scription of M. Pinel, there is no more ataxic 
fever, than adynamic fever without gastro-en- 
terite. 

When the first of these diseases is manifes- 
ted after a wound or an external inflammation, 
it is necessary, then, after having done 'all to 
moderate its violence, to apply leeches on the 
head and the epigastrium, placing them in the 
greatest number, or even exclusively on the 
parts which correspond to the seat of the first 
and most intense inflammation. It is in these 
very changeable affections, when the nervous 
system is especially affected, that revulsives 
procure often unexpected success. 

Among the inflammations, besides the vari- 
ous shades of gastro-enterites, which most fre- 
quently complicate wounds, and which pro- 
duce the greatest ravages in hospitals, acute 
colitis occupies the first place. It may confine 
itself to that degree of violence which we call 
diarrhoea, or it may arrive at such a degree as 
to form true dysenteries: it consists always in 
an active irritation of the large intestines, ordi- 



APPLIED TO SURGERY. 91 

narily produced by the use of bad aliments. It 
is proper, in consequence, to oppose it by a 
strict diet, and drinks containing some farinace- 
ous and feculent substance, as rice water, white 
decoction, etc. A small quantity of opium, ad- 
ded to these liquids, is very useful, in as much 
as it tends to diminish the peristaltic motions of 
the small intestines, to retard the progress of 
alimentary substances in these organs, and to 
give a necessary repose to the last portions of 
the digestive canal, which the arrival of the 
foecal materials constantly irritates. The local 
remedies the most suitable, are mucilaginous 
lavements, and, if the symptoms have a high 
degree of intensity, leeches applied to the anus, 
more or less considerable in number, according 
to the strength of the patients. It is by a sim- 
ilar treatment that Broussais can arrest in a few 
hours the most violent acute diarrhoeas ; and 
there is no doubt that the remedies of which 
this method is composed would produce the 
most happy effects, if we would make use of 
them in the army, to combat the epidemics, so 
frequent and so fatal, of that formidable disease. 
It is hardly necessary to add that when to the 



92 PHYSIOLOGICAL DOCTRINE, 

symptoms of irritation of the large intestines are 
joined those which characterize inflammation 
of the superior part of the alimentary canal, the 
disease is more serious, and that-it is necessary 
to unite to the medications which have been 
pointed out, those, the use of which gastro-en- 
terite demands. 

The details into which I have entered may 
seem minute to some persons ; but let the pre- 
cepts on which I have thought it my duty to 
insist, be compared to the therapeutical methods 
still adopted by a great number of surgeons, and 
they will be convinced, I hope, of all their impor- 
tance. Do they not every day see ippecacuanha 
used to combat the first stages of peritonites 
in cases of parturient women, and even those, 
which threaten the patients on whom the oper- 
ation of cystotomy has been performed ? Is not 
an emetic recommended by the greatest number 
of writers, and administered in a baneful manner 
to patients having wounds of the head ? Do 
they not lavish tonics in every form, as soon as 
general debility complicates external irritations? 
Do not the most powerful local stimulants yet 
appear too feeble to some practitioners to com- 



APPLIED TO SURGERY. 93 

bat the pretended passive inflammations which 
threaten to terminate by gangrene ? Do not 
purgatives form a necessary part of the prepa- 
rations which patients are required to submit to, 
who are about to undergo severe operations ? 
In a word, does not surgery present a crowd of 
errors which compromises every day, both the 
interests of art, and the most sacred rights of 
humanity ? The efforts employed for the refu- 
tation of these errors, and the establishment of 
truths which ought to occupy their place, will 
always be favourably received by men who think 
that medico-chirurgical theory and practice are 
still susceptible of improvement, 



94 PHYSIOLOGICAL DOCTRINE; 

Chapter V. 

JYervous affections determined by acute 
surgical lesions. 

On the considerable development and power- 
ful action of the nervous system in man, depend 
the manifestation of a great number of serious 
affections, in consequence of injuries produced 
by external bodies. When an animal has been 
wounded, almost always he remains easy and 
tranquil ; no inquietude agitatates him, and the 
phenomena of local irritation, likewise those of 
the sympathetic stimulation of the viscera are 
manifested without any thing occuring to prevent 
their appearance, interrupt their course, derange 
or prevent the order of their succession. This 
simplicity and regularity in the development of 
pathological phenomena is very rarely met with 
in man. The thousand circumstances by which 
he is attacked and which often strike his mind 
with terror; the exaggerated idea which he 
has of the danger of the wound, the passions 
which agitate him at the moment when he has 
been injured, are some of the causes, which 



APPLIED TO SURGERY. 95 

often, carrying with them a profound effect 
upon his nervous system, determine affections 
the most serious, and even death. It is true, 
that, on some occasions, opposite moral disposi- 
tions, seem to reanimate the subjects and pro- 
long their lives : we have seen men in whom 
the mind has been borne up by fanaticism, or 
impressed with the idea that their wounds were 
trivial, become, in a manner, from this moral 
exaltation, this consoling hope, the preservation 
of their existence, after injuries, which, with 
others, would have been almost inevitably mor- 
tal. 

The surgeon, like the physician, finds occa- 
sions when moral medicine can be employed 
with advantage. Thus, when the minds of the 
wounded are depressed by gloomy ideas, by the 
fear of imminent danger, or approaching death, 
he ought to combat all these, to prevent im- 
pressions so fatal. We have already done a 
great deal for the cure of the disease, when we 
have calmed these inquietudes, moderated these 
passions, and eased a too intense imagination. 
This indication is even urgent ; and it is proper 
to be fulfiled, at the same time that we are oc- 



96 PHYSIOLOGICAL DOCTRINE, 

cupied with the dressing of the wounds and the 
employment of means the most proper to pre- 
vent the local and general affections which often 
succeed them. When, on the contrary, the ideas 
of the patient are of such a nature as to conceal 
from him tine seriousness of his disease, and to 
give him the hope of a happy recovery, it is im- 
portant to cherish them, without neglecting on 
this account, the use of other more suitable 
means of treatment. 

Among the most remarkable nervous affec- 
tions which often complicate wounds, stupor, 
convulsions, traumatic tetanus and delirium are 
the most important, the most dangerous, and 
those only which will be considered in this 
chapter. 

The stupor, ordinarily produced by a com- 
motion or agitation of the nerves, is much more 
rare than we would be apt to think, after read- 
ing a great number of works on surgery. With 
the exception of those cases of wounds of the 
head, and direct commotion of the central parts 
of the nervous system, I have scarcely ever ob- 
served this affection. The stupor may be local 
or general. In the first case, the injured part 



APPLIED TO SURGERY. 9? 

appears insensible, inert, and as if without life. 
The energy of the capillary vessels about it ap- 
pears to be diminished; the integuments are cold; 
and very soon a livid engorgement which easily 
terminates by gangrene, manifests itself, and 
makes rapid progress. When the stupor is gen- 
eral, it produces a numbness accompanied with 
weight in the whole body; the visage is pale, 
sometimes yellowish and livid; intense coldness 
and shivering are manifested; the pulse is small, 
slow, and concentrated; we observe in fine, a 
sort of annihilation of all the organic actions 
and of all the functions. 

These affections were attributed by the an- 
cients to the deleterious action of projectiles put 
in motion by cannonry. 

The stupor is ordinarily augmented by the 
terror of the patient; it may even depend almost 
entirely on this cause; at least we have observed 
phenomena not unlike those which characterize 
it, among persons who have happened to escape 
from very great dangers, notwithstanding they 
have not even received any wound. Often, the 
stupor is accompanied by a state of hebetude 
carried so far, that the patient cannot take any 
13 



98 PHYSIOLOGICAL DOCTRINE, 

interest in things which he ought to feel most. 
It was thus with the light-horseman, of whom 
Quesnay speaks ; who, upon being asked if he 
w r ould consent to have his leg cut off, answered, 
—that, that was none of his business. 

The phenomena of stupor are ordinarily tran- 
sient: to the concussion, and suspension of ner- 
vous action, succeeds very soon, among most 
patients, a strong reaction, which determines 
both the re-establishment of the heat of the 
skin, and the fulness and frequency of the pulse, 
the return of the general sensibility, and the de- 
velopment of the muscular forces. This change, 
sometimes takes place with such rapidity, that 
we have not time to oppose any remedy to the 
primitive affections. But, on some occasions, 
the state of stupor continues during many hours 
or even days, and we ought to put promptly in 
use, the means most proper to cause it to cease. 

If for some time after wounds, the pulse is 
small and concentrated, the skin pale, cold, and 
shriveled, and the sensibility and contractility 
considerably weakened, the most pressing indi- 
cation which the practitioner ought to fulfil, con- 
sists in restoring the forces, exciting the regular 



APPLIED TO SURGERY. 99 

action of the nervous system, and consequently 
that of the heart, the lungs, and the other or- 
ganic apparatuses. Exciting substances, such 
as wine, infusions of linden, ftilia europcea,) 
distilled waters of canella, orange-tree flowers, 
ether, and other preparations of the same kind, 
are then administered with advantage. We 
obtain sufficiently excellent effects from warm 
frictions and superficial irritants on the skin. It 
is proper, in cases of local stupor, to direct espe- 
cially tonics and stimulants towards the injured 
part. The practitioner ought to continue the 
employment of these means, until the state of 
stupor be completely removed; but as soon as 
the signs of sanguineous and nervous reaction 
are manifested, it is necessary to change the 
medication, and to have recourse to the general 
and local anti-phlogistic treatment which has 
been already mentioned, and the advantages of 
which I have many times already demonstrated. 
One important remark which ought to be 
mentioned in this place, is, that we ought not 
to confound with stupor, either the state of 
insensibility and sinking which accompanies 
drunkeness, or the general prostration produced 



100 PHYSIOLOGICAL DOCTRINE, 

by the strong sanguineous congestions of which 
the wounded viscera are frequently the seat. In 
the first case, the commemorative circumstances 
are sufficient to give light to a diagnostic, and 
the practitioner ought to wait for the cessation 
of the somnolency. In the second, the abscence 
of all commotion, the manifestation of affections, 
not at the moment of the wound, but some time 
after, are the circumstances which ought to 
guide the surgeon, and direct him to employ 
general and local sanguineous depletions, soon^ 
er than exciting substances, which aggravate 
the disease in place of removing it. 

Ordinarily produced, either by the lesion of 
some filament or some nervous trunk, or by the 
excess of pain of which the wounded and infla- 
med parts are the seat, convulsions constitute 
a very serious complication of external affec- 
tions. Among certain very susceptible individ- 
uals, they have always a moral cause, as terror, 
or the impression produced by some spectacle 
of carnage and destruction. In the first case, it 
is necessary in order to put a stop to the convul- 
sive movements, to make a section of the nerves, 
or to remove, by means of local bleedings and 



APPLIED TO SURGERY. 101 

emollient applications, the excess of irritation 
which produces them. Under the other circum- 
stances, we obtain salutary effects from the 
administration of antispasmodics united with 
narcotics, and administered in small doses often 
repeated. 

The causes of tetanus are still enveloped in 
a great deal of obscurity, and we are scarcely 
possessed of any positive knowledge, concern- 
ing the means of treatment which we ought to 
oppose to it. It appears nevertheless, that in 
almost all spasms, the affection depends con- 
stantly on an irritation of some important part 
of the economy.* Among the wounded, this 
irritation resides very often, no doubt, in the 
injured part itself: it is thus, that we see the 
tetanic rigidity manifest itself after wounds by 
tearing, and those which are accompanied by 
the dilaceration of very nervous and sensible 
parts; as the hands, the feet, and the neighbor- 
hood of articulations, etc. But causes of this 
kind are not those alone which can determine 



* See the excellent article Tetanos, which M. Fournier-Poscay 
has inserted in the Dictionnaire des sciences medicates. 



102 PHYSIOLOGICAL DOCTRINE, 

the affection of which we speak. Vicissitudes 
of heat and cold; the sudden suppression of the 
cutaneous transpiration; a gastrite more or less 
intense; the disturbance produced by intestinal 
worms; these are some of the circumstances 
which most frequently determine tetanus, even 
among subjects affected with wounds. It would 
be easy for me to cite observations where I have 
seen this disease provoked by each of the causes 
which I have enumerated. The wounded are 
much more exposed to tetanic affections, be- 
cause they are more susceptible of impressions , 
and their nervous system is stimulated by the 
local lesion; finally, their sympathies are more 
active, and there exists already, a manifest dis- 
turbance in their organic actions. 

Surgeons have committed a serious error, in 
wishing always to find in the wounds them- 
selves, the causes of tetanus. A man, for ex- 
ample, is wounded on the finger; the wound, 
continuing to the tenth day, is a lively red, and 
covered by a healthy suppuration; there exists 
in the part neither sloughing, tumefaction, nor 
pain. In the mean while, the patient, after 
having taken exercise, lies down, fatigued, on 



APPLIED TO SURGERY. 103 

his bed, near an open window; he becomes 
chilly very soon; shiverings come on, and some 
hours after, tetanus is developed. They then 
lavish opium; they explore the wound in order 
to be certain that there is not any foreign body 
concealed in it; finally, they cut off the wound- 
ed part, and the patient dies. I demand, was 
it not absurd to search in the wound for the 
cause of tetanic affection? Did not this depend 
on the impression made by the cold on the in- 
teguments, and was it not developed after the 
same mechanism as the tetanus which destroys, 
under similar circumstances, children, and above 
all young negroes, between the tropics? How 
often have errors of this kind been committed, 
and how often have they not accused the 
wounds of provoking the tetanus which was 
manifestly determined by gastro-intestinal irri- 
tations! On some occasions, it has appeared 
to me that cold, falling upon the surface of 
solutions of continuity in a state of suppuration, 
could determine the affection of which we are 
speaking, by provoking a true metastasis of ir- 
ritation to the central parts of the nervous sys- 
tem. Then, the wound becomes dried up, pale, 



104 PHYSIOLOGICAL DOCTRINE, 

wan, and sometimes insensible, at the same 
time that the tetanic rigidity is developed and 
makes its progress. 

In the same manner as surgeons for the most 
part have attributed tetanus to a single cause, 
some amongst them have wished to combat it 
by one common treatment applicable to all 
cases, thus joining to errors of theory, those a 
great deal more serious, of practice. Antispas- 
modics, opium in frightful doses, baths, sangui- 
neous evacuations, have been employed over 
and over, and have procured some successes to 
a multitude of others the reverse. But if these 
means have been sometimes useful, they must 
necessarily have combatted the cause of the 
disease ; and if observers could have enabled 
us to distinguish from all the others, the cases 
when this or that medication has succeeded, it 
would be actually possible to imitate them. But 
being deprived of this knowledge, we can only 
proceed by useless gropings in the dark, or by 
the often whimsical union of opposite medica- 
ments. Hence, the hesitation of practitioners 
and the rarity of success. It is for pathological 
physiology, it is for those surgeons enlightened 



APPLIED TO SURGERY. 105 

by the new medical doctrine, to renew the his- 
tory of tetanus. No doubt, that, to combat 
efficaciously this terrible affection, we ought to 
remove its true causes, and oppose proper means 
to each of them. It is thus that incisions, the 
section of nerves incompletely divided, the ex- 
traction of foreign bodies, and even the complete 
removal of the wounded parts, are sometimes 
necessary ; it is thus that we can employ with 
advantage, when we are able to use with dis- 
cernment, sometimes narcotics or vermifuges, 
sometimes diet and epigastric bleedings, finally, 
sometimes, sudorifics, baths, warm and stimula- 
ting frictions on the skin, etc. 

To this treatment, variable according to the 
causes of the disease, it will be necessary, I 
think, to join bleedings produced by the appli- 
cation of leeches to the temples, the back of 
the neck, and along the spinal column. Every 
thing leads us to think, that, during tetanus, the 
brain, the spinal marrow, and the rachidian pro^ 
longation, are the seat of some irritation, or 
rather that the tetanic rigidity is no more than 
an effect of this irritation, which is itself deter- 
mined by the stimulation of some other part of 
14 



106 PHYSIOLOGICAL DOCTRINE, 

the body. I have seen at Dresden, a soldier 
affected with tetanus, who presented all the 
signs of a considerable sanguineous cerebral 
congestion. I bled from the temporal artery, 
and all at once I observed his mouth open, his 
speech become free, and the general stiffness 
diminish a great deal. The symptoms, never- 
theless, reappeared, and the patient died ; but it 
serves to show how advantageous local bleed- 
ings might have then been. Of the rest of 
the plan of treatment which I have pointed out 
here, it has only reasoning and analogy in its 
favour; it is for experience to confirm or con- 
demn the inductions on which it is founded. 

Cerebral irritation, sympathetically determin- 
ed by acute affections of the external parts of 
the body, sometimes gives place to a very 
remarkable affection, which has received the 
name of traumatic delirium* This delirium, 
characterized by a sort of moral exaltation, 
arises, either in consequence of wounds, or great 
operations. It manifests itself especially among 
nervous subjects, in whom the intellectual fac- 
ulties are susceptible of receiving and retaining 
strong impressions. We observe it frequently 



APPLIED TO SURGERY. 107 

after attempts to commit suicide; among those 
patients who have made violent efforts to con- 
tain themselves or to affect a stoic courag^ 
during surgical operations; finally, in soldiers, 
after combats in which thek valor and intre- 
pidity have been depressed by great trials. 

Traumatic delirium commences sometimes by 
unconnected words, and incoherent movements 
without motive. In the greatest number of ca- 
ses, it takes complete possession of the patient. 
Sometimes we observe an extreme loquacity; 
the eyes are red and protruding, the visage 
animated, the movements of the limbs and body 
disorderly. The remembrance of the wound or 
the operation is entirely lost; and the nervous 
action is in a measure perverted, and we ob- 
serve the patients disturb the affected parts, 
throw far off the pieces of dressing, and bruise, 
and mangle their wounds without manifesting 
any pain. We have seen the wounded in this 
deplorable state, walk on their fractured limbs, 
and on the projecting extremities of fragments; 
others take a barbarous pleasure in dividing 
their intestines through the abdominal wounds. 
It is not rare, in the army, to see soldiers run- 



108 PHYSIOLOGICAL DOCTRINE, 

ning over the wards thinking themselves still 
on the field of battle. The men who have 
wished to put themselves to death, tear off with 
fury, the dressings which cover them, and renew 
their attempts at suicide* They are not sensi- 
ble to the want of sleep; the patients remain 
vigilant as long as the excitement of their im- 
agination is continued; the appetite is void; no 
excitation of the pulse, no febrile action is man- 
ifested; and the alvine evacuations take place 
with the same regularity as in the normal state. 
The duration of this affection is very variable: 
sometimes it ceases in two or three hours ; some- 
times on the contrary, it agitates the patients for 
three or four days. It terminates ordinarily all 
at once, either by the recovery, or death of the 
patient. In the first case, its cessation is an- 
nounced by a general oppression, and by a 
sleep of eight, twelve, or a greater number of 
hours; after which, we find the patient in a 
calm state, his reason returned, sensible of the 
pains produced by his wounds, and asking to 
be dressed, likewise not having any remem- 
brance of that which he has experienced. When 
death takes place, which is rare, it happens 



APPLIED TO SURGERY. 109 

amidst the most violent agitation; we observe 
the forces then gradually diminish, the respira- 
tion become difficult, the pulse slow, and the 
vital actions become extinguished; the delirium, 
nevertheless, continues to the last moments. 
The bodies of patients who have sunk in this 
singular state, have not offered any constant 
affection, either of the brain, or the other vis- 
cera of the economy. 

In considering both the temperament of indi- 
viduals, who are especially exposed to traumatic 
delirium, and the cause likewise, and the symp- 
toms of this affection, it becomes incontestable 
that it depends on a cerebral super-excitation. 
It constitutes a true temporary madness, produ- 
ced on the one hand, by the moral commotion 
which the individual has experienced at the 
time of the wound, and on the other, by the 
sympathetic excitation which the wound deter- 
mines in the central parts of the nervous system. 
Pathological physiology explains these phenom- 
ena in the most satisfactory manner: this is a 
new proof of the importance of its study to the 
surgeon. 



110 PHYSIOLOGICAL DOCTRINE, - 

We have combatted traumatic delirium with 
anodynes, antispasmodics, revulsives, and bleed- 
ings pushed so far as to produce fainting, with- 
out these remedies having manifestly exercised 
any influence on the progress of this affection. 
M. Dupuytren, who has for a long time devoted 
the whole of his attention to the subject, has 
combatted it with the greatest success, by means 
of the laudanum of Sydenham injected into 
the rectum, in the dose of eight or ten drops 
mixed in two or three ounces of mucilage. 
These lavements, which are easily prepared, 
are to be repeated three or four times in the 
interval of five or six hours : they suffice almost 
always to produce sleep and restore perfect tran- 
quility.* 

The disease alluded to, consisting of a vio- 
lent excitation of cerebral action without pro- 
found lesion of the tissue of the brain, narcotics 
ought to succeed better in its treatment than 
other soothing substances, and even bleedings. 
I am, nevertheless, disposed to think, that leech- 
es placed on the back of the neck, at the same 

* Annuaire medico-chirurgical des hopitaux et hospices civils 
de Paris, torn. 1, p. 145. 



APPLIED TO SURGERY. Ill 

time that we cover the head with ice and place 
the feet in a hot bath or envelop them with sin- 
apisms, will succeed as well. But as the method 
which we have pointed out, and which is very 
simple in its application, procures almost con- 
stant success, we should not substitute for it, 
another, before we have put the same in use. 

However strange it may seem, it is very re- 
markable, that the preparations of opium have 
an action more rapid and more energetic when 
introduced into the rectum, than when they are 
administered by the mouth. I have had suffi- 
ciently frequent occasions for employing this 
medication, and I ordinarily employ a solution 
of gum opium for that purpose. Injected through 
the anus, this substance produces sleep, without 
determining the general excitation which we so 
often observe when it is made to come in con- 
tact with the stomach. Does this phenomenon 
depend upon this : that the nerves of the rectum 
have a- peculiar susceptibility for transmitting 
the effects of opium, or, which is more proba- 
ble, the intestines being deprived of the diges- 
tive faculty, alter this medicament less than the 



112 PHYSIOLOGICAL DOCTRINE, 

stomach? This question is difficult to solve* 
It is proper to observe, that, in a great number 
of cases, the stomach being irritated, with- 
out the practitioners having taken account of 
this state, they have considered the results of 
the impressions made by that substance on the 
inflamed membrane of the stomach, as the phe- 
nomena depending upon the action of opium. 
Administered by the rectum, when it is in a 
normal state, narcotics have none of these in- 
conveniences. Could we not employ them with 
advantage, in this way, in certain cases of mad- 
ness ? Analogy permits us to suppose so ; but 
experience alone can give it demonstration. 



APPLIED TO SURGERY. 113 

Chapter VI. 

Local alterations determined by chronic 
surgical lesions. 

Under the title of chronic surgical lesions, I 
comprehend those which affect the external 
parts of the body, and in which the duration, 
almost always undetermined, continues for some 
time. This definition is not strict, and has no 
need to be so, for the end which I propose to 
attain: it is sufficient for me to have examined 
in the preceding chapters, the primitive, local, 
and sympathetic phenomena produced by acute 
surgical diseases, and to have established the 
basis of their treatment. If nothing complicates 
these affections, if there should arise no unfor- 
seen accident, simple dressings, aided by a suit- 
able regimen, are sufficient to conduct the pa- 
tients to a recovery, in which nature herself 
effects almost all. I have then, no more need 
of occupying myself with them. In the fol- 
lowing chapters I will give a history of the 
diseases which have not had a place in the 
preceding category, and in which, their march, 
15 



114 PHYSIOLOGICAL DOCTRINE, 

far from tending to a recovery, seems to consist, 
on the contrary, in making always increasing 
progress. 

Nearly all chronic surgical diseases are formed 
by different irritations, fixed on certain organs, 
and extending themselves, ordinarily, to many 
tissues. Wounds which suppurate, ulcers, tu- 
mours produced either by engorgement of the 
lymphatic ganglions, or by the afflux and solidi- 
fication of the fluids in the capillary vessels, or 
in the cellular areolae ; the numerous lesions of 
articular parts, which some have hitherto con- 
founded under the name of white swelling; ulce- 
rations of the bones, hydrops articulorum, ulcera- 
tions produced by the residence of foreign bodies 
in living parts; fistulas formed by the perfora- 
tion of the excretory canals or the reservoirs of 
certain fluids, such as the tears, the saliva, the 
bile, the urine, the stercoral materials, etc.; all 
those diseases which occupy almost all surgi- 
cal nosographies, are evidently the result of 
chronic inflammation of the organs of which 
they are the seat, or at least, inflammation 
formes their principal character. These affec- 
tions, among the greatest number of individuals. 



APPLIED TO SURGERY. 115 

succeeding wounds or acute inflammations, pre- 
sent the fundamental phenomena of irritation: 
they give place to pain, swelling, suppuration, 
and all the symptoms which accompany the too 
intense excitation of the organic movements* 
Diseases, even those which seem to remove 
most positively all idea of irritation, as necroses, 
varices, infiltrations called passive, either of 
blood or serum, in the cellular tissue, muscular 
or fibrous relaxations, etc., are complicated very 
easily, and very frequently, with an irritation 
more or less intense. It is for this reason, that 
after necroses, often produced themselves by 
phlegmasia, the tissues which cover the dead 
portion of bone, are constantly inflamed and ul- 
cerated. Varicose veins become, in a great many 
individuals, the seat of an inflammation which 
has for its effect, the distruction of the coats 
of these vessels, and the effusion of the fluid 
which they contain. The parts distended by 
the blood or by the serosity in hemorrhoids, or 
in anasarca, become easily red, hot, and pain- 
ful, by the irritation which these fluids deter- 
mine by dilating them beyond their proper size. 



116 PHYSIOLOGICAL DOCTRINE, 

Finally, the fibrous or muscular relaxations, 
have often for effect, the fatigue of the articu- 
lations and shortly the inflammation of the 
ligaments, the cartilages, and the synovial 
membranes. Finally, every where, in surgical 
diseases as well as in those which are under the 
exclusive influence of internal medicine, we find 
evident phenomena of local super-excitation; 
and it is on the exterior as well as in the inte- 
rior of the body, through means of chronic in- 
flammation, that the affected tissues are ulcer- 
ated, destroyed, or acquiring new qualities, are 
transformed into abnormal tissues more or less 
estranged from the primitive type of their or- 
ganization. 

Among the diseases which I enumerate, there 
are some on which it is important to fix espe- 
cially the attention of practitioners, because the 
physiologico-pathological principles which con- 
cern them, are not yet universally adopted, and 
many surgeons, having embraced incorrect tile- 
ries, are far from combatting them by means the 
most suitable and most efficacious. Those dis- 
eases are scrofula, chronic inflammations of the 
joints, and cancer. 



APPLIED TO SURGERY. 117 

1st. Of scrofula. I think I have demon- 
strated and placed beyond all contention, that 
principle already admitted by Girtanner, that 
the lymphatic temperament is exclusively owe- 
ing, to the excessive development and predomi- 
nance of action, of the system formed by the 
ganglions and lymphatic vessels.* To this 
general disposition is joined, almost always, the 
exuberant nutrition of the cellular, adipose, and 
fibrous tissues; likewise the greatest activity of 
all the organs charged with mucous, serous and 
synovial secretions. In a word, in the lymphatic 
temperament, the white tissues seem to subdue 
by their extent, the organs which the blood 
animates almost exclusively, as the muscles; 
and the white elaborations prevail in energy, 
over the hsematosis, which remains imperfect, 
and languishes. 

These general propositions being admitted, it 
is incontestable, that the disposition to scrofula 
consists in the too great irritability of the lym- 
phatic vessels and ganglions, and that scrofula 

» — — — — — — — . — ' i • -. 

* Principes generaux de physiologie pathologique, in 8vo. Paris, 
1821. 



118 PHYSIOLOGICAL DOCTRINE, 

itself, is nothing more than irritations of these 
parts, more or less intense. Broussais has given 
to this disease the name of sub-inflammation ; 
but this word is inexact, in as much as it does 
not indicate the part which is especially affected. 
I think then, we should prefer that of ganglion- 
itis, which is better adapted to the nature and 
seat of the disease. 

Those? are its subjects, in whom we observe 
the lymphatic ganglions of the neck or of all 
the other parts of the body swollen, at the same 
time that they become hot and painful, and the 
redness of their tissue is propagated to the integ- 
uments which cover them. Ganglionitis is then 
manifested: irritation and inflammation are an- 
nounced by unequivocal signs; and emollient 
applications, likewise local bleedings, have al- 
most constant success. Is the nature of the 
disease changed when the same tumours are 
not accompanied by redness of the skin, and 
the pain is less intense and the heat less consid- 
erable? It is impossible to admit it; for, even 
in these cases, the tumefaction has presented, 
in its beginning, evident phenomena of irrita- 
tion; phenomena which it is easy to renew by 



APPLIED TO SURGERY. 119 

making use of irritating substances, and which 
may reappear spontaneously after a time more 
or less long, when the tumour softens and is 
converted into an abscess. 

For the most part, the inflammations of in- 
ternal ganglions depend on the inflammation of 
the mucous membranes on which are opened 
the lymphatic vessels which return to the ogans 
affected. External ganglionites occur from 
analogous causes. It is ordinarily in conse- 
quence of irritations of the integuments of the 
skull, or of those of the gums and the mouth, at 
the period of dentition, that the ganglions of 
the neck among infants become inflamed. We 
see very often, the ganglions of the axillas and 
groins become inflamed and even turn into ab- 
scesses, after wounds, inflammations, or ulcera- 
tions of the fingers or toes. Now, all, these 
ganglionites accidentally at first acute, persist, 
frequently, in individuals eminently lymphatic; 
and, when they become chronic, long after the 
causes which determined their appearance have 
ceased to act, they give them the insignificant 
and barbarous name of scrofula; they mistake 
their origin, and oppose to them a treatment the 



120 PHYSIOLOGICAL DOCTRINE, 

most empirical and unreasonable. Neverthe- 
less, the same vital modification which charac- 
terizes them at first, protracts them. It is the 
same when the ganglions are tumified on the 
exterior, without a known cause, and with more 
or less slowness. In effect, whether the gan- 
glionites be accompanied or not by redness and 
pain, it constitutes only an accessary circum- 
stance, which does not change at all, the nature 
of the disease; it proves only, that among certain 
individuals, the irritation is more intense, the 
congestion more rapid, and the sanguinious cap- 
illary vessels more stimulated, than amongst 
others. That which is fundamental, is the 
afflux of the fluids towards the parts; it is the 
morbid action which operates on these, and 
which announces always the existence of local 
irritation; for irritation alone can attract the 
the materials of nutrition to some points in a 
greater quantity than to others. * 

* The view which Broussais takes of the manner in which the 
affection called scrofulous, takes place, deserves a place here. 
" In the human economy," says he, "there are a certain number 
of tissues, on which nature has bestowed but little irritability, 
which receive but few blood-vessels and nerves, and which remain 
unaffected by most of the emotions that we experience in the nor- 
mal state. The sympathies of these appear latent, and inflamma- 



APPLIED TO SURGERY. 121 

§ II. Of chronic inflammations of the joints. 

Authors have established different theories rela- 
tive to diseases of this kind. Confounded under 

tion attacks them more rarely than it does any of the others ; in 
arranging these tissues according to the inverse order of their 
vitality, we find the cellular tissue, the lymphatic system, of which 
the ganglions constitute the most complex part, the periosteum, 
the ligaments, the cartilages and the bones. In a well-organized 
adult, these tissues rarely and with difficulty become inflamed, and 
they always receive irritation from those that are more sanguineous 
more nervous and more irritable than themselves. In infancy, 
they are more readily irritated, the lymphatic system always feels 
very promptly any irritation of the surfaces of relation of the pa- 
renchymatous secretories, and soon contracts an inflammation, 
more considerable than that of the tissues from which the irrita- 
tion had been transmitted to it. Nevertheless, this disposition 
varies according to the constitution of the patients; those in whom 
it is most marked are called scrofulous ; in them the skin and mu- 
cous openings are more irritable than in other children; the 
mucous and sebaceous follicles, and generally all the secreting 
capsules are also very irritable ; and the slightest phlogosis of these 
tissues heats and tumefies the adjoining capsules, as well as the 
lymphatic vessels which communicate with them. The neighbor- 
ing cellular tissues are more or less implicated. 

However, these irritations, far from advancing rapidly to sup- 
puration, become chronic, produce lymphatic tumefactions, which 
are more or less voluminous, and of various shapes, and cause 
disorganization very slowly. 

Such is the first grade of the scrofulous disposition or diathesis. 
Its effects, as has been seen, are confined to the soft tissues of the 
periphery of the body ; the most striking fact it appears to us is, 
that these tissues are more irritable than they ought to be, and 
this even reaches such a degree that the action of cold on the 
skin, or the most trifling contusion, are sufficient to develop 
scrofulous sub-inflammations. Nevertheless, tissues which are 
more deeply situated, more dense and less vital, are not yet affec- 
ted ; but, in a higher grade of the diathesis in question, they soon 
become so ; the periosteum, ligaments, cartilages, and bones, lose 
their density and their insensibility, and become the seat of white 
or lymphatic tumefactions; true- sub-inflammations, having still 

16 



122 PHYSIOLOGICAL DOCTRINE, 

the most rediculous name of white swellings, 
they have been considered as the incomprehen- 
sible results of the development of a pretended 

less heat than the preceding, and in which disorganization is still 
more difficult. 

Let us examine this new fact without any bias, and as if we 
had forgotten all that has been written on it by authors. What 
do we observe ? Is it not dependent on a vicious irritability of the 
tissues in question? Is it not from their want of cohesion, or their 
too great aptitude to soften and swell, in short, to their propensity 
to lose their peculiar character of insensibility and immobility, and 
to assume those of the other tissues, which they formerly resem- 
bled when in the fetal state,and from which,according to general 
opinion, they had definitively diverged 1 Is not the above the idea 
that would be formed of these diseases, by a person versed in ana- 
tomicel knowledge, and habituated to rely on what he saw, if he 
had never heard of strumous virus or principles,, of scrofulous hu- 
mours, and of all the entities which the spirit of hypothesis has 
invented as respects this disease ? Such a person would pity the 
unhappy sufferers afflicted with a white swelling of the articula- 
tions, from a fall on the elbows, the wrists, or the knees, not that 
their blood was impure, but for not having their bones and liga- 
ments sufficiently solid, for having them too much allied to the 
constitution of the soft parts. Well ! this person we think would 
have a much juster idea of the scrofulous state than the authors of 
all the nosological works we possess on this disease. 

But what then is rachitis ? It is still, in our view of the subject, 
the most palpable proof we can adduce to prove the assertion we 
have just made. There are young patients in whom the combi- 
nation of the phosphate of lime with the gelatine of the bones is 
not sufficiently strong, sufficiently perfect, to prevent the weight 
of the body, the pressure of the viscera, or the constant contraction 
of the muscles, from causing the separation of solidifying salt. 
But compare this separation with that which happens to a bone 
in a vigorous adult, in whom the periosteum and the medullary 
tissues are inflamed ; will you deny, in the latter case, that the 
inflammation of tissues closely attached to the bones and penetra- 
ting into their parenchyma, has not introduced irritation there, 
and that it was not by awakening their irritability that the phos^ 
phate of lime in them was separated 1 Certainly you cannot deny 



APPLIED TO SURGERY. 123 

scrofulous, gouty or rheumatic defect. They 
have made themselves rediculous by explaining 
their formation and progress, and their different 
characters, by the accretion of the lymph, the 
debility of the affected parts, the obstruction of 
the vessels, etc. None of these hypotheses can 
stand a rigid examination ; and none have been 
generally adopted by practitioners. These im- 
pure remains of a humoral and ontological pa- 

these propositions. Well ! add to this fact the cases where the 
two fragments of a broken bone become soft, that is, lose their 
phosphate of lime during the inflammation, and regain it when 
this action has disappeared : will it not result, that it is in losing 
their irritability that the gelatinous tissues, formed to be associated 
with the calcareous phosphate, can unite with this salt in infancy, 
and that, if by accident, they should recover this irritability, it 
necessarily happens that this phosphate must a second time be 
separated from them 1 

With such data, the fact of osteo malaxis is as well explained 
as it can be : children in whom the osseous parenchymata retain 
irritability for a long time, are subject to .softening, that is, to 
the separation or reabsorption of the phosphate of lime in such of 
their bones as are most exposed to irritation. It is in consequence 
of this law that we see osteo-malaxis developed in them in the 
regions of the spinal column, and the lower extremities, which 
support the greatest weight, and that phlegmasia^ which attack 
their articulations, induce more or less softening and tumefaction 
of these parts. 

It is hence evident, that the principle of scrofula is the same 
as that of osteo-malaxis, and that if these two modes of alteration 
do not always act in concert, the difference can only arise from 
the degree of the vicious irritability, which we have mentioned, 
and the direction accidentally taken by the causes capable of 
inducing an attack of the disease. Principles of Physiolog. Med. 
— Trans, 



124 PHYSIOLOGICAL DOCTKIftE, 

thology, are still found in works on surgery, the 
most recent, the most esteemed and the most 
extensively used. They reckon, even in our 
days, to the reproach of science, partisans who 
defend them with so much more violence, as 
they know that the period of their entire oblite- 
ration is not far off. 

Study the causes, examine the beginning, fol- 
low ther progress of articular lesions, and you 
will acquire easily the conviction that they are 
the result of a more or less intense inflamma- 
tion of the affected parts. At first acute, and 
determined by some external violence, this in- 
flammation is continued to the chronic state ; 
primitively fixed on those tissues which environ 
or constitute the joint, it is gradually extended 
to others, and finishes by disorganizing com- 
pletely the whole articulation. Considered in 
relation to their seat, articular inflammations 
may attack: 1st. The cellulo-fibrous tissue 
which covers the articulations ; 2nd : The liga- 
ments proper to the joints themselves ; 3d : The 
periosteum on the extremities of the bones ; 4th: 
The synovial membranes ; 5th : The cartilages: 



APPLIED TO SURGERY. 125 

6th : The bones themselves.* If we make 
post mortem examinations at different periods 
of the duration of the disease, we will find con- 
stantly in one of the tissues designated, altera- 
tions more or less profound: such as thickenings, 
purulent infiltrations, ramollissements, ulcera- 
tions, or scirrhous, cancerous, melanose, or oth- 
er degeneracies. Now, these disorders are con- 
stantly the product of a local inflammation. 
And, after the disease has made more or less 
considerable progress, we find the parts primi- 
tively affected, more or less completely disor- 
ganized, and the disorder extending itself more 
or less far in the other tissues, either to the ex- 
terior or the interior of the articulation. It is 
thus, that I have seen knees in which inflamma- 
tion had required the amputation of the leg, 
present in some subjects, only a deep erosion of 
the articular cartilages ; among others, ramoU 

* This manner of studying articular inflammation is that 
alone which can permit us to give a satisfactory account of the 
phenomena of the disease, and to oppose to it a methodical treat- 
ment. The irritation, the inflammation and disorganization of 
each of the parts enumerated, are announced by particular signs 
which it is important to observe with care, and which furnish sure* 
bases to the diagnosis and prognosis of the affection. I have de- 
monstrated the advantages of the classification alluded to, in the 
article Arthrocace,in the Dictionmire abrege des sciences medicule?. 



126 PHYSIOLOGICAL DOCTRINE, 

lissements, or fungous degeneracies of the liga^ 
ments, etc. Who has not observed, after chron- 
ic inflammations of the coxo- femoral articula- 
tion, sometimes the cartilages, sometimes the 
bones, sometimes the articular capsule, eroded, 
destroyed, or converted into a lardaceous sub- 
stance ? These varieties are multiplied almost 
ad infinitum ; but it is only by studying with 
attention the progress of inflammation that we 
can form correct ideas of the* nature, the ex- 
tent and danger of the diseases which it con- 
stitutes. 

§ III. Of Cancer. It would be of but little 
use to repeat here, for the sake of combatting 
them, the numerous and often incoherent opin- 
ions of physicians, on the natnre of cancerous 
affections. The most recent, and perhaps, 
the least reasonable of the theories promul- 
gated on this subject, is that which makes can- 
cer to consist in a new organ, formed out of all 
the constituents of our parts, and which is de- 
veloped in us like a parasitic plant, to which 
nothing has served as a germ. This metaphysi- 
cal hypothesis, founded on a most excessive ig- 
norance of the laws of the organization, is al- 



APPLIED TO SURGERY. 127 

ready almost entirely obliterated. Broussais 
has well demonstrated the imperfections, I might 
almost say the absurdity, which a small number 
of physicians, enthusiasts of Bayle, and con- 
flders in the school of pathological anatomy of 
which he became in some sort the head, dare 
still alone to maintain, and to resist at the same 
time, better contested facts, and reasonings the 
most peremptory. 

Chirurgical nosography, which appears to 
be the last refuge of all the errors which physi- 
cians have recently abjured, and which sees its 
editions multiply without participating in the 
progress of science ; chirurgical nosography has 
preserved with care, the division of diseases 
into class, order, genera, and species. Amongst 
these genera, we find those of primitive tuber- 
cles and cancers, or those created spontaneously 
in the living parts, without these parts them- 
selves having any thing in them to serve for the 
formation of these new productions. If it is 
curious to observe how the human mind can 
discard the voice of observation and logic, it is 
a great deal more so to observe, how it can 



128 PHYSIOLOGICAL DOCTRINE, 

persist in its obstinacy in caressing ancient 
chimeras, and rejecting recent truths. 

Nevertheless, nature seems to have underta- 
ken the task of pointing out to those who ob- 
serve without prejudice, what are the origin and 
progress of cancerous affections. She shows 
that almost all tumours of this kind are the result, 
more or less distant, of external violences direct- 
ed against the parts of which they are the seat. 
The inflammation, at first acute, which has 
succeeded to these physical lesions, is only im- 
perfectly removed, and a slight circumscribed 
engorgement, more or less solid and painful, 
succeeds it; which indicates, that a portion of 
tissue, more contused than the rest, has pre- 
served the irritation, after all that which envi- 
rons it, is restored to its normal state. If the 
rest of the irritation is methodically combatted, 
a recovery is achieved; but if the disease is ne- 
glected, and,for a stronger reason,if we apply on 
the tumour irritating substances, it makes rapid 
progress; the fluids flow towards it in a greater 
quantity from the new degrees of stimulation 
which it acquires, and its development becomes 
considerable. 



APPLIED TO SURGERY. 129 

If any one pretends, that this theory is not 
an exact and rigorous expression of facts, new 
observations can be brought forward which can 
confirm its correctness. The external tissues of 
the body being frequently the seat of chronic 
inflammations, we see these diseases, when 
they are prolonged for a time more or less con- 
tinued, determine notable changes in the nutri- 
tion of the parts affected. The heat, redness, 
and pain, signs of acute inflammation, disap- 
pear insensibly; the irritated tissues become 
more dense, more thick, and more compact than 
in their natural state; they seem to solidify 
themselves, to use the expression, and they 
acquire, in fine, the characters of that which 
we have designated, under the name of organic 
production, with or without analogy in the liv- 
ing economy. 

Whilst the irritation continues to act, either 
because we have not given any thing to remove 
it, or because we have exasperated it by the 
application of irritating substances, we observe 
the tumour become infiltrated with a yellow 
serum, or a pulpous and whitish matter: the 
areolae seem to dig into its tissue, and the latter, 
17 



130 PHYSIOLOGICAL DOCTRINE, 

compressed on all sides, finally disappears. The 
tumour is then converted into a cerebriform 
pulctaceous, melanose, or other mass. 

Transformations of this kind operate con- 
stantly from the centre to the circumference of 
the affected parts, that is to say upon the por- 
tions of tissue which have been irritated first, to 
those which the inflammation has invaded only 
secondarily. This pathological labour operates 
at first, with leniency and without determining 
intense pains; but when it is advanced, that is 
to say, when the ramollissement commences, 
the pains are awakened, the acute inflammation 
is renewed, and haemorrhages take place in the 
middle of the tumour. Then a decomposing ac- 
tion seems to take possession of the latter; the 
parts which cover it are ulcerated, and the sore 
which they form, ordinarily covered with bleed- 
ing funguses and furnishing an abundant putrid 
ichor, makes more or less considerable progress, 
and carries the patient inevitably to the tomb. 

These details of pathological anatomy are 
not founded on vain suppositions; they have 
not alone for their bases the researches of 
Broussais and his deciples, whom they might 



APPLIED TO SURGERY* 131 

accuse of prejudice; they repose on the labours 
and description of Bayle, Laennec, arid anato- 
mists who have occupied themselves of late 
with the greatest success, in the study of mor- 
bid organic productions. 

We may then divide the progress of cancer- 
ous affections into four periods; which are, 1st., 
that of the passage of the inflammation from 
the acute to the chronic state; 2d., that of the 
thickening, the solidification of the tissues, and 
the development of the scirrhous state ; 3d., that 
of the infiltration into the cellulo-fibrous inter- 
stices of the scirrhus, of a serous or pulctaceous 
matter, which distends, compresses, and destroys 
them, and finishes by producing a ramollisse- 
ment of the entire mass; 4th., lastly, that of the 
renewal of the acute inflammation, which de- 
termines the ulceration and destruction of the 
parts which cover and border upon the tumour. 

There is a point in this theory which merits 
especially to fix the attention of practitioners; 
it is the mechanism by which the ramollisse* 
merit of the fibrous or scirrhous tissues which 
degenerate into cancer is produced. It appears 
to me, that the ramollissement is always the 



132 PHYSIOLOGICAL DOCTRINE, 

result of an infiltration, of which the morbid 
tissue is the seat. We find, in effect, tumours 
hard and a little old, formed by a whitish shin- 
ing tissue, composed itself of laminae, or of 
concentric fibres, crossing each other diversed- 
ly, and cracking under the bistoury, In pro- 
portion as we examine these tumours at a pe- 
riod more advanced, and especially when the 
lancinating pains have become sensible, we find 
the original and firm state of the morbid tissue 
more altered by serous or pulpy matter. The 
entire mass being divided, it is easy then, by 
sqeezing it as we would an orange, to press out 
the infiltrated substance, which leaves bare the 
fibrous elements of the tumour. Finally, at a 
period still more distant from the origin of the 
disease, we find the pulctaceous matter collected 
almost alone in the centre of the cancerous 
mass, the other parts preserving still a certain 
degree of solidity. The intense pains which 
are then manifested, the renewal of acute irri- 
tation, the exhalation of blood in the cancerous 
place, and the haemorrhages produced by the 
rupture of vessels, depend, probably, both on 
the compression of the fibrous portion of the 



APPLIED TO SURGERY. 133 

morbid tissue, and the decomposition* of the 
cancerous mass, and finally by the stimulation 
exercised by it on the parts which circumscribe 
it. 

It may be objected, perhaps, that the preced- 
ing theoretical explications, applicable to can- 
cerous degeneracies of organs, cannot be appli- 
cable to spontaneous productions of tubercles 
and cancers. This objection is more special 
than solid; for it is impossible for any man who 
observes and who reasons, to admit, that can- 
cerous organs are able to spring forth sponta- 
neously, and to develop themselves without 
causes in our parts. Irritating actions, more or 
less active, have preceded their appearance ; 
and when, they are developed, the cancerous 
tumours seem to destroy the neighbouring tis- 
sues, to wear them out by compression, without 
having any direct communication with them ; 
they constitute a special form of the disease, 
but nothing proves that they originate sponta- 

* By the term decomposition, I do not mean either a chemical 
decomposition, or a putrid alteration ; I wish to designate the 
change of properties which the increased vital action, or irritation, 
impresses on the nutritive materials which it has made to abound 
in the parts, and on the morbid tissues, which it has, we may say, 
created. 



134 PHYSIOLOGICAL DOCTRINE, 

neously. When, after an inflammatory en- 
gorgement more or less considerable, there re- 
mains in the parts, a hard, solid and moveable 
kernel, it may, and often does happen, that the 
small tumour, instead of encroaching succes- 
sively, and spreading itself, to use the expres- 
sion, in the neighbouring parts, increases itself 
by means of the vessels which penetrate it, and 
the irritation of which it is the seat enlarges it 
more every day. Then, its development takes 
place from the centre to the circumference, and 
its periphery remains distinct from the middle of 
the tissues which it displaces. It is almost al- 
ways in this manner, that the fibrous tumours 
implanted either in the aponeuroses, the liga- 
ments, or the bones, or in the mucous mem- 
branes, are formed and extended ; and in the 
mean time we never think of presenting these 
tumours, as spontaneous organic productions, 
and to which, no tissue, no vessel, has served as 
the origin. The schirrhi developed in the lymph- 
atic ganglions, and of which the base is fibrous, 
are almost always in the same situation, and 
becoming softened, form among many indivi- 



APPLIED TO SURGERY. 135 

duals, those circumscribed cancers of which we 
have spoken so much. 

Finally, the authors of monographies on can- 
cer, have insisted a great deal on the infiltration 
of the cancerous matter into the meshes of the 
primitive tissues, in which they could recognize 
the structure disencumbering itself of the fo- 
reign substance which overloaded it. But in 
admitting the accuracy of this fact, what does 
it prove ? Nothing else, than that under some 
circumstances, and amongst certain individuals, 
the fluids which the irritation called for, and 
which the affected part modified in this manner 
were deposited in the substance of the organs, 
not yet altered, being able then to acquire that 
pulpy softness, which we consider as one of the 
essential characteristics of softened cancer. — 
But if we admit, that this whitish pulp belongs 
exclusively to cancerous affections, these affec- 
tions will be indeed more frequent than authors 
think. 

After almost all chronic ententes, we find in 
the mesentery, ganglions disorganized, softened, 
and containing nothing more than a similar 
matter. This last is met with often enough, in 



136 PHYSIOLOGICAL DOCTRINE, 

certain cellular engorgements on the exterior of 
the body. In all these cases, there is a forma- 
tion of a pulctaceous matter, through the influ- 
ence of local irritation; but this pulp is not of 
a cancerous nature, and the cancers diffused by 
infiltration, of which we have spoken, do not 
appear to me to exist naturally. 

Do I speak here of cutaneous cancers, or of 
phagedenic ulcers? These terrible diseases, 
the progress of which it is so difficult to arrest, 
are indeed manifestly the result of a local irrita- 
tion, and most ordinarily produced, by stimula- 
tion a long time continued, by solutions of con- 
tinuity which nothing indicated as having a 
tendency to assume this character. It is thus 
that wounds of the face at first simple, vesica- 
tories, those more superficial still, have acquired 
in consequence of the prolonged abuse of infla- 
ting substances, the phagedenic character. The 
cancerous pimples of which all authors speak, 
are not followed, for the most part, by the phe- 
nomena which succeed them, if the patients, 
instead of tearing their summits and the crust 
which is renewed on their surfaces, cover them 
with topical emollients, and above all, abstain 



APPLIED TO SURGERY. 137 

from irritating them. It is not until after a 
while, that is to say, until the ulcer is develop- 
ed, that we recognize that the pimple which 
has given birth to it, was cancerous; knowledge 
which it is, nevertheless, neither difficult nor 
profitable to acquire, since the evil is done, and 
only requires to be combatted.* 

* On the subject of cancer, Broussais makes the following 
remarks : — " When an eroding ulcer occurs at the surface of the 
body, physicians endeavour to discover its cause. If they can sus- 
pect a venereal, scrofulous, herpetic or other principle, for there 
are many other species of it, the ulcer is named and treated ac- 
cordingly. If it be cured, it retains its epithet ; if all attempts to 
arrest its progress are vain, it is declared to be cancerous. It 
even sometimes happens that it is necessary to recal this last 
epithet in consequence of its having been given too soon ; and it 
is necessary to do that whenever the disease is cured, since it is 
agreed that cancer is incurable. 

When no cause could be assigned for inflammations which 
were supposed to arise from a humoral principle, curable by 
specifics and depuratives, and in cases where the eroding ulcer 
was formed on a chronic engorgement, the title of cancer was at 
first bestowed on it ; if, however, notwithstanding the prognosis 
of the physician, the patient was so fortunate as to recover, the 
first diagnosis was obliged to be abandoned, and if the ulcer could 
not be attributed to any virus or any morbid principle, it was 
finally said that it was an ulcer simulating cancer, h^t not of the 
same nature as that disease ; and all this because cancer must 
necessarily be an incurable disease. 

That a disease termed cancer should exist, which must neces- 
sarily be beyond all the resources of art, is what a young phy- 
sician would readily suppose at first ; but when he demands the 
distinctive characters of this disease, no one can give them to 
him ; no practitioner knows whether an external ulcer was really 
of a cancerous nature, until the death or cure of the patient re- 
vealed to him this great mystery. 

The appearance of the ulcerated surface not furnishing suf- 

18 



188 PHYSIOLOGICAL DOCTRINE, 

Chapter VII. 

Local treatment of Chronic Surgical Dis- 
eases. 

The theoretical principles exposed in the pre- 

ficient data for the solution of the question, physicians have had 
recourse to the subjacent tumefaction. They undertook to assign 
characters to it, but did not agree what these characters were. 
Some thought it must necessarily be a medullary sarcoma, a kind 
of 6paque lymphatic tumefaction, having some relation in colour 
and consistence to the brain ; others that it was a lardaceous tis- 
sue ; some preferred attributing it to a tissue having a fibrous ap- 
pearance, formed of gelatine, resembling the pulp of an orange, 
(all the tissues may in fact partake in the ulceration of the skin, 
or of any other membrane of relation ;) but eroding and incurable 
ulcers were also pointed out to them, developed on the surface 
of the skin and external mucous membranes, without any of these 
tissues having been previously formed. At the present time we 
can show them encephaloid, lardaceous, and scirrhous masses, 
some of which h-ave been removed by the knife, and others have 
been cured by the application of leeches. 

It may also be demanded of them, why, if there must always 
exist one of their tissues priviledged for the formation of cancer, 
they do not give this name to scrofulous, scorbutic, leprous or 
herpetic ulcers, &c. when all their endeavours to cure them have 
been ineffectual. The same question may be put to them as re- 
gards all ulcerations which they do not attribute to any virus, 
and it will be seen that their answers will always be uucertain. 
They have no means of ascertaining either by the touch in feeling 
the tumour, or by the appearance of the ulcer, whether it will 
be cured or not, and as the essence of cancer is in its incurability, 
they cannot give or withhold this name till after the event. 

Such was still the state of the science when the propositions 
in the Examination of Medical Doctrines appeared, for what 
the author had already written some ) r ears previous on the same 
subject had not made a sufficient impression. The erroneous cir- 
cle in which medical men revolved, in reasoning on phthisis pul- 



APPLIED TO SURGERY. 139 

ceding chapter, and the exactness of which, the 
physiological doctrine has placed beyond doubt, 
are of the highest importance in surgery. They 

monalis, equally served them as regarded the theory of cancer, 
and it was to free medicine from these disgraceful ambiguities, 
these shocking contradictions, that the author having given in a 
detailed manner in the Examination of Medical Doctrines, all 
the demonstrations which the nature of these two diseases appear- 
ed to him susceptible of, made a summary of them and inserted 
them in his general propositions. We have seen, in the proper 
place, those which related to phthisis pulmonalis ; as to those 
under consideration, we have but little to say to explain them, it 
will be sufficient to refer to facts in as concise a manner as a sub- 
ject will admit. 

All chronic inflammations of the surface of the body, may, if 
immediately irritated whilst the gastric passages are stimulated, 
be converted into eroding ulcers ; and these ulcers, becoming in- 
curable by the destruction which they have occasioned, by the 
depth to which they have penetrated, -as well as by the pi ogress 
of the concomitant visceral irritation, become what authors have 
called cancers. 

All external sub -inflammations are not precisely in the same 
predicament, because there are some among them, of such an 
indolent nature, that nothing can develop in them the degree of 
irritation necessary to induce the disorganizing phlegmasia. 

As to phlegmasia^ of the viscera, it is seldom that they are so 
destitute of irritability that stimulation will not produce the ero- 
ding and disorganizing state in them, when it is repeated vio- 
lently and incessantly. The only exceptions to this rule are 
the white or lymphatic engorgements, situated beyond the in- 
flnence of irritants in the gastric passages, as tumefactions of the 
ovaries, those of the inter- visceral fatty tissues, which are often 
insensible to the stimulation of the internal surfaces of relation; 
we sometimes see them continue during life without undergoing 
the cancerous degeneration. There are cases, however, where 
their volume have occasioned their adhesion to the skin, this being 
more irritable and sanguineous than they are, and being exces- 
sively distended, is attacked with a chronic phlegmasia, which first 
ulcerates it, and after having destroyed it, reaches the hitherto 
indolent tumour, and invests it with the cancerous character. 



140 PHYSIOLOGICAL DOCTRINE, 

throw strong lights on. the treatment of that 
multitude of diseases to which they opposed 
almost nothing but general or local excitants, 
destined to dissolve the lymph, to correct the 
acrimony of the fluids, to give strength to the 
vessels to disencumber themselves of the mat- 
ters which engorged them, finally, to 
render to all the parts the tone of which they 
supposed them to be deprived. These indica- 
tions, which are still proposed in certain chirur- 
gical nosographies, and of which the system of 
Brown, or a loathesome humorism has furnish- 
ed the basis, do not merit any more to be com- 



The same alteration may take place in these tumours, from 
the ulcerated surfaces of internal mucous membranes, when they 
are situated sufficiently near to each other. It is thus that the 
tumours of the bronchial ganglions, which for a very long time 
were preserved exempt from any solution of continuity, may be 
implicated by an ulceration of the mucous membrane of the 
branchiae, which, after having destroyed this membrane, attacks 
the gland which adheres to it, and penetrates more or less into its 
substance. 

The same disorder may invade the liver or the spleen, when 
ulceration has perforated the stomach or an intestine adhering to 
these indurated parenchymata. 

It is only very dry or very moist engorgements which cannot 
be attacked by the disorganizing phlegmasia, and which are in 
no danger of cancer. Finally, to terminate by the most general 
fact, all chronic inflammations and sub-inflammations susceptible 
of being exasperated by the action of stimulants, may, if they be 
long subjected to this proof, be converted into cancers." Elements 
ofPhysiolog. Med. — Trans. 



APPLIED TO SURGERY. 114 

batted; they are in plain opposition to the least 
contested progress of pathology and pathologi- 
cal physiology. The details into which I have 
entered concerning the nature of those diseases 
to which they are applied, exempt me from dis- 
cussing them here anew : the antiquated ma- 
terials of the systems from which they are de- 
duced being overturned, the practical conse- 
quences of those systems ought to be annihi- 
lated. 

It has resulted from the preceding discussions, 
that irritation is the nearest cause of most of 
the affections which the surgeon ought to treat. 
It remains for me to examine what are actual- 
ly the means, in general, the most proper to re- 
move this irritation, and by what rules it be- 
comes us to proceed, to cure the principal dis- 
eases which it constitutes. 

For the most part, ulcers which are not con- 
tinued, either by foreign bodies or local altera- 
tions which oppose mechanically their cicatri- 
zation, or by general disorders in the constitu- 
tion of the patients, yield to the use of simple 
dressings, suitable hygienic means; and a regi- 
men adapted to the state of the digestive or- 



142 PHYSIOLOGICAL DOCTRINE, 

gans. When the solutions of continuity alluded 
to, are covered with granulations that are pale, 
fungous, soft, insensible, and bathed with a se- 
rous and badly elaborated pus, the cicatrization 
not progressing, if the patient is feeble without 
presenting the signs of visceral excitation, it is 
indicative of the internal administration of tonic 
substances and of having recourse locally to 
stimulating applications. Among patients plac- 
ed under such circumstances, the ulcer presents 
a manifest irritation, but which is too feeble to 
cause the affected parts to undergo the succes- 
sive transformations which the organization of 
the cicatrice requires. The tissue of this last 
has need, like the callus of bones, for a degree 
of inflammation sufficiently considerable tor it 
to be formed ;« and in those cases where this in- 
flammation does not exist, it is necessary to pro- 
duce artificially, an excitation of the wound by 
pledgets soaked in wine, the decoction of bark, 
alcohol, the application of fused nitrate of sil- 
ver, and even by the aid of direct cauterization. 
To admit the existence of atonic ulcers, is to 
suppose that feebleness can destroy the continu- 
ity of the parts ; that which is opposed to all 



APPLIED TO SURGERY. 148 

the laws of animal organization. It is true, 
that a state of general or local debility favours 
the action of the irritating causes which deter- 
mined the ulceration ; but the latter is not less 
the incontestable result of the stimulation of the 
affected parts. Whether this irritation be feeble 
or considerable, its existence is not less attested 
by the presence even of the solution of continuity 
which it has produced and which it maintains. 
If they had called atonic those ulcers only which 
are not sufficiently inflamed to progress towards 
a recovery, there would have been some shadow T 
of reason in this manner of discriminating ; but 
to attach that term to wounds produced by the 
irritating action of cold liquids, and accompa- 
nied by such inflammatory swelling that it is 
necessary to cover them, for many hours, with 
emollient cataplasms, can only take place 
by a strange reversion of the better demonstrav 
ted principles of pathological physiology. 

The solutions of continuity which irritating 
dressings have for a long time maintained, and 
in which the edges, subdued by the influence 
of chronic inflammation, are covered with indu- 
rations, have healed with a remarkable promp- 



144 PHYSIOLOGICAL DOCTRINE, 

titude, by means of topical emollients, and local 
bleedings performed by the aid of leeches. This 
observation is not new; but it merits to be re- 
collected, because it gives undeniable proofs 
of the good effects of sanguineous depletions 
against external irritations sufficiently advanced 
for to have already profoundly altered the tex- 
ture of the parts of which they were the seat. 
The case alluded to, is one of those where 
compression, methodically exercised and joined 
to gentle and loose dressings, is followed by 
rapid and almost marvellous success. 

Tetters, scald-heads, and all those eruptions 
which authors have so eagerly strived to multi- 
ply the species and varieties, consist only in 
irritations more or less intense of the cebaceous 
follicles and exhalent vessels of the skin. Many 
amongst them are maintained by the same 
means which they employ to combat them, 
they increase in extent by the action of the ir- 
ritating substances with which they cover them. 
It is but a short time since, that I saw a young 
person affected with a furfuraceous tetter on 
the right side of the thorax. At first slight, little 
painful,and characterized solely by the presence 



APPLIED TO SURGERY. * 145 

of some scurfy desquamations, this exanthema 
made rapid progress under the influence of the 
waters of Bareges, and other topical stimulants; 
in a few weeks the integuments about it were 
red, tumified, and very sensible; the scurfs were 
more thick, and they appeared then to cover 
deep erosions, confirmed ulcerations. Baths, 
emollient cataplasms, relaxing fomentations, 
light purges often repeated, sufficed in a short 
time to disperse, with all the symptoms, even 
the last traces of the tetter which produced 
them. 

The physiological doctrine is frequently use- 
ful in a great number of cases where ancient 
systems leave practitioners without a guide in 
the midst of contradictory symptoms. I have 
actually under my eyes a young girl, for whom 
I was consulted in the month of November, 
1822. This young person was affected with 
an insupportable affection, which consisted in 
exhaling by the nose, an unwholesome and dis- 
agreeable odour. Her parents repelled her, 
none of her companions could associate with 
her in the sports and amusements of childhood, 
The physicians consulted, had declared that 
19 



146 PHYSIOLOGICAL DOCTRINE, 

the disease was situated in the bronchise or the 
lungs, which they supposed ulcerated and in a 
state of suppuration. Bitters, anti-scorbutics, 
and an animal diet, were prescribed without 
success : the disease instead of diminishing 
made continued progress. The patient and 
the whole family were in great affliction. I 
was then applied to. The chest of the young 
person was well formed, percussion and the 
stethoscope did not announce any alteration in 
the organs which it enclosed. The patient 
never had experienced any pain in this part; 
the complexion was good, the pulse without 
frequency, the coloration natural, the embon- 
point tolerable. This aggregate of phenomena 
made me judge at once, that there did not exist 
any profound and chronic alterations in the or- 
gans of respiration. But the young girl had expe- 
rienced frequent pains in the head; a constant 
foulness manifested itself in the nasal fossae; the 
mucous secreted by the pituitary membrane was 
yellow, thick, abundant, and presented the offen- 
sive odour which accompanied the respiration. 
Finally, by examining attentively, the nasal 
mucous offered evident traces of inflammation : 



APPLIED TO SURGERY. 147 

and all the time that the pains of the head, the 
stoppage in the nose, (enchifrenement) and the 
pituitary secretion were augmented, the odour 
became more offensive and insupportable. It 
was evident, after these symptoms, that the na- 
sal mucous membrane was the exclusive seat 
of the disease, and that the latter consisted in 
a chronic irritation, or perhaps, in ulcerations 
of that part. In consequence of this diagnostic, 
leeches were applied during the paroxysms of 
cephalagia; emollient fumigations had been di- 
rected to the nasal fossae ; perspiration was exci- 
ted by means of baths and under-waistcoats of 
flannel habitually worn next the skin; mild 
purgatives completed the system of revulsives 
which I proposed to follow. The disease had 
lasted many years, it had resisted all stimulants; 
and it yielded in two months and a half to the 
treatment which I have pointed out. The 
young person is actually exempt from all indis- 
position, her gayety is returned, her embonpoint 
has made progress, and for a long time no person 
has perceived any exhalation of a disagreeable 
odour. 



148 PHYSIOLOGICAL DOCTRINE, 

Fistulee, for the cure of which so many ope- 
rations and so many different instruments have 
been contrived, are sometimes susceptible of 
being completely cured by a local antiphlogis- 
tic treatment, employed with method and per- 
severance. Lachrymal fistulee, for example, 
depend a great deal more frequently than com- 
mon practitioners think, on inflammation and 
tumefaction of the mucous membrane of the 
nasal canal. In those cases, when there is only 
a dilation of the lachrymal sac, or when the 
tears have already opened a passage on the 
cheek, emollient injections, pushed through the 
lachrymal points or through the fistulse, and 
leeches applied to the great angle of the eye 
and on the side of the nose corresponding to 
the disease, frequently succeeds, as M. Demours 
has observed, in destroying the inflammation 
and thickening of the affected mucous mem- 
brane, in such a manner that the normal pas- 
sage being re-established, the fluid takes its 
accustomed route. Then the tumour formed 
by the lachrymal sac or the perforation of this 
reservoir gradually disappears. It is necessary 
to acknowledge, nevertheless, that this treat- 



APPLIED TO SURGERY. 149 

ment is tedious, and that the result being sub- 
ordinate to the patience and exactitude of the 
afflicted, success does not constantly crown the 
efforts of the most skilful practitioner. The 
compression exercised on the inflamed mem- 
brane by the canule of Dupuytren is a remedy 
far more expeditious and more sure. This in- • 
strument does not produce any inconvenience ; 
when it is left in place for several months, and 
by accident it becomes detached and falls into 
the nasal fossae, the cure which it has procured 
is no less continuous. 

Fistulous passages, although organized and 
furnished with an abnormal, thick and resisting 
mucous membrane, is constantly obliterated in 
a very short time, under the influence of emol- 
lient applications, after we have diverted the 
course of the irritating fluids which maintained 
them. 

Caries of the bones are incontestably the 
immediate effect of irritation and ulceration of 
the tissue of these organs. Therefore, it is ne- 
cessary, when the affected part is painful and 
inflamed, to cover it with topical emollients, 
whatever be otherwise the general debility of 



150 PHYSIOLOGICAL DOCTRINE, 

the patient. I have been witnessing for the 
last year, the spontaneous healing of a caries of 
the bones of the foot produced by a blow from 
the point of a scythe, in a full grown and vigo- 
rous man. The primitive wound, which had 
not united by the first intention, continued, 
and furnished some weeks after the accident, 
a grayish suppuration; a probe pushed into 
the deepest part, evinced that the bones de- 
prived of their periosteum, were rough and soft- 
ened. From this, the caries was evident, and 
they made use of stimulants of all kinds to the 
exterior. Far from yielding, the disease became 
more stubborn, and more extensive; an inflam- 
mation accompanied with oedema and a bluish 
colour of the integuments, had already invaded 
the whole of the middle portion of the foot, and 
the means employed to combat it, not being suc- 
cessful, amputation was proposed. To this the 
patient refused to submit. Having abandoned 
his foot to nature, he observed absolute repose, 
and confined himself to the employment of cat- 
aplasms and emollient baths. He very soon 
observed the pain diminish and entirely cease, 
the inflammation and swelling disappear, and 



APPLIED TO SURGERY. 151 

the ulcer take on a more favourable aspect. 
Three tolerable large pieces of bone came away 
successively, and the cicatrization of the wonnd 
was not long in taking place after their expul- 
sion. 

Observations of this kind are not rare in the 
records of science; they show that surgeons 
have made too general and too exclusive a use 
of topical irritants in caries of the bones, and 
that there are cases, more numerous than most 
practioners think, where emollient applications, 
rest, and antiphlogistics are a great deal more 
suitable and more efficacious. 

Nevertheless, when the caries does not yield 
to the soothing treatment, and when all the 
intense local inflammation appears to be remov- 
ed, experience has proved the good effects which 
are produced by baths and pourings of alkaline, 
soapy, hydro-sulphurated, and chalybeate wa- 
ters, etc. Applications and injections made 
with the tincture of myrrh and aloes, the use 
of essential oils, or of the oil of turpentine, are 
sometimes followed by the cure of slight and 
superficial caries. Aromatic vapour baths, di- 
rected on the affected parts, have been frequent- 



152 PHYSIOLOGICAL DOCTRINE, 

ly advantageous. These remedies, all stimula- 
ting the parts, appear to change their mode of 
action, and to produce in them a degree of 
irritation different from thai which maintained 
the caries. Cauterization, so powerful against 
this affection, determines, in like manner we 
know, the death or necrosis of all the portion 
of diseased bone, and provokes in the adjacent 
layers an intense excitation, which is followed 
by the development of cellular and vascular 
granulations of a healthy nature. 

Since the experience of Tenon in the treat- 
ment of necroses, it is well demonstrated, that 
essential oils, alcoholic tinctures and other stim- 
ulating remedies, serve only to retard the sepa- 
ration of the osseous flakes destroyed by death. 
Emollient applications hasten, on the contrary, 
the development of cellular and vascular granu- 
lations, and the formation of a solid eschar 
which covers them. It appears that the topicals 
of the first kind augment the irritation, and, in 
a manner, parches up the vessels, whilst the 
others produce a general relaxation which is 
followed by a shooting forth of the capillary 



APPLIED TO SURGERY. 158 

texture, and a more active growth from the 
bottom of the wound. 

After having taken a rapid glance at the 
treatment of some of the most frequent surgical 
lesions, it remains for us to examine the reme- 
dies to be employed against the diseases which 
have been especially the subject of the preced- 
ing chapter. 

§ I. Treatment of external scrofulous af- 
fections. As soon as the tumours formed by 
the lymphatic ganglions have become pale, 
indolent and stationary, it is the custom to 
cover them with stimulating plasters. Now, 
experience proves, that these means are ineffi- 
cacious and even injurious in the greatest num- 
ber of patients. They are only fit to root more 
deeply the irritation in the affected organ. Un- 
der their influence, the tumours become ordina- 
rily more hard and unyielding. Who has not 
soen ganglionites of the groin, when we cover 
them too much with the plaster of Vigo, or 
when we rub them with ammonical linament 
before resolution be almost already completed, 
acquire a considerable solidity, resist in conse- 
quence all resolvents, and continue in the same 
20 



154 PHYSIOLOGICAL DOCTRINE, 

state for many years? To say, that the reper- 
cussives have then dispersed the most liquid 
portion of the engorgement and that the debil- 
itated vessels could not disembarras themselves 
of the rest,* is to reproduce those humoral and 
mechanical theories a long time since despised 
by enlightened physicians. We are astonished 
that doctrines so contrary to observation should 
still find partizans at the present day. The 
fact is, that stimulating applications augment 
the .irritation, in the cases alluded to, and hast- 
en the progress of fibrous and scirrhous trans- 
formations which it tends to impress on the 
parts which it invades. 

It seems that in the cases of which we are 
now speaking, surgeons become impatient to 
have recourse to irritating substances: they 
fear of loseing a day in employing topical relax- 
ants. I have, nevertheless, seen ganglionites 
which had obstinately resisted the most active 
resolvents and the most powerful tonics of the 
materia medica, disappear, as by enchantment, 
under the influence of leeches and emollient 
cataplasms continued with perseverance. — 



* 



JSTosographie chirurgicale, torn. I, page 174. 



APPLIED TO SURGERY. 155 

Practitioners have not paid sufficient attention, 
among children, to the causes which have pro- 
duced ganglionites of the neGk; they do not 
take sufficient account of eruptions of the in- 
teguments of the skull, of denticular irritations, 
of habitual coldness of the head, of the neck 
and arms. Nevertheless, to remove at first the 
exciting causes of the disease, and then to have 
recourse to local bleedings and emollient appli- 
cations, should form the basis of treatment to 
be employed against these pretended scrofulas. 
This is what reason indicates, and the advanta- 
ges of which, experience already confirms. 

If the patient is really in need, and the diges- 
tive viscera do not present any sign of irrita- 
tion, this local antiphlogistic treatment does 
not prevent from having recourse to aliments 
that are nourishing and of a good quality ; to 
the use of old Bordeaux wine; to elixer of gen- 
tian with the addition of the carbonate of soda 
orbarytes; to gymnastic exercises in the open 
air; in a word, to all those means which, aug- 
menting the energy of the sanguineous system, 
and distributing in a manner, the vital move- 
ments with agility in all the parts of the body, 



156 PHYSIOLOGICAL DOCTRINE, 

destroy the morbid predominance of action 
which possesses the lymphatic system in gen- 
eral, and the affected parts in particular.* 

Treatment of articular inflammations. The 
preceding observations are applicable to chronic 
inflammations of the joints. These affections 
are of the number of those, which, for the most 
part, surgeons have been in the habit of treat- 
ing by means of the most energetic irritating 
substances. After having exhausted the long 
list of linaments and mercurial, ammoniacal, or 
sulphurous frictions; alkaline, chalybeate and 
sulphurous baths ; cataplasms, aromatic plants 
boiled in wine, &c. they have recourse to vesi- 



* Of all the hygienic means recommended against scrofulous 
diseases there is none more powerful, and more salutary than the 
gymnastic. And in relation to this, Paris offers resources which 
we in vain look for elsewhere. An extensive gymnasium, directed 
by M. Amaros, and patronized by the ministers of war and the in- 
terior, is here constantly opened to the public. This establish- 
ment surpasses by its extent, the multiplicity of machines which 
we find here collected, the method of instruction which is followed, 
and the precautions of all kind by which children are surrounded, 
that which antiquity has offered us as one of the most wonderful 
of the kind. A physician presides over all the exercises of the 
gymnasium, in order to adapt it to the nature of the infirmities 
which it is intended to oppose. We find already in this establish- 
ment, woithy of the benevolence of all philanthropists, a great 
number of examples of the cure of scrofulous diseases and of differ- 
ent deviations either of the vertebral column, or of the shoulders 
and limbs. 



APPLIED TO SURGERY. 157 

eateries, moxa, and cauteries. A treatment of 
this kind, in which they make use of only excit- 
ing means, where revulsives are employed before 
the irritation has been sufficiently reduced, serves 
only to aggravate the disease; therefore, for 
some very rare successes obtained by this meth- 
od, and which they cite every moment, we see 
cases multiply every day where chronic diseases 
of the joints terminate by the death of the pa- 
tients or necessitate the amputation of the limbs. 
In the mean time experience proves, that 
local bleedings, absolute repose of the parts af- 
fected, baths, and emollient applications, are 
the most efficacious means which art can oppose 
to chronic arthrites. Rest alone, has procured 
for M. Bouchet of Lyons, unexpected success 
in diseases of the knee. He keeps this articu- 
lation immoveable, fixing the entire limb in a 
gutter composed of two parts which can move 
one upon the other, either by flexing, or by 
extending the leg. These two gutters, in which 
we fix the two parts of the limb by means of 
straps, are re-united by a trammel placed on 
the side of the apparatus, near the knee, and 
which invariablv confines the movements of 



158 PHYSIOLOGICAL DOCTRINE, 

this articulation. Remarkable cures have been 
thus obtained, sometimes with the complete pre- 
servation of the mobility of the limb ; in other 
cases, with anchyloses, sometimes fibro-liga^- 
mentous, sometimes osseous. 

M. Janson, of the Hotel-Dieu of Lyons, suc- 
cessor to the celebrated practitioner whom I 
have already mentioned, continues to employ 
this method; he joins to it solely the application 
of dry and warm topicals and resolutive sachels, 
or exutories around the tumour. This treat- 
ment is a great deal more simple than that, the 
pretended excellence of which is generally ex- 
tolled by authors. Nevertheless, new observa- 
tions have demonstrated, that to rest, it is more 
advantageous to join local bleedings frequently 
repeated, than excitants ornamented with the 
title of resolutives. Many authentic examples 
of healing of arthrites, old and almost entirely 
given up, have taken place recently at Paris, 
in one of the most frequented hospitals, and 
every thing induces us to think, that observa- 
tions of this kind will multiply more and more 
every day, in proportion as the principles of the 



APPLIED TO SURGERY. 159 

new medical doctrine become more generally 
adopted by surgeons. 

It is only when by means of local sanguine- 
ous evacuations, we have obtained a reduction 
of the irritation, that vesicatories, moxas and 
cauteries, are certainly useful to combat chronic 
articular inflammations. This practical truth 
is applicable to the treatment of all external 
inflammations. Until we have abated the flux- 
ionary movement, likewise the pain and heat 
which accompanies it, revulsives will not pro- 
duce any good effect; the irritation is too in- 
tense, too rooted, to be easily removed, and the 
stimulant action which they are intended to 
counter-ballance, turns then entirely in its favor, 
and augments its intensity. It is thus, that in 
arthrites of the knee and of the hips, I have 
twenty times seen vesicatories and moxas exas- 
perate all the symptoms and determine in the 
patients a violent fever. Begin then always 
with rest, local bleedings, a strict and soothing 
diet; if the pain is intense, cover the part with 
emollient cataplasms; otherwise be content with 
enveloping it with flannel. Heat, moisture, 
and cataplasms to the feet, frequently favour 



160 PHYSIOLOGICAL DOCTRINE, 

the soft and oedematous swelling of the cel- 
lular tissue; they are consequently hurtful all 
the time that there exists an indolent engorge- 
ment of the external parts of the articulation. 
The patient should often take warm-baths, which 
advantageously serve the place of cataplasms, 
favour the perspiration, and are at the same 
time emollients and revulsives. 

It is only when by means of this antiphlogis- 
tic treatment, we have obtained a notable dimi- 
nution of the irritation and phlogosis, that vesi- 
catories, moxas, or the actual cautery can be 
profitable; they then produce sometimes won- 
derful effects. The local irritants destined to 
strengthen the parts should not be used until 
the cure is finished: that is to say, when the 
last remains of the irritation being removed, 
they only serve to give the articulation, really 
debilitated, its primitive solidity. Then, baths 
and pumpings with sulphurous mineral waters, 
placing the affected parts in liquids charged 
with emollient principles, -movements and exer- 
cise gradually increased, are highly proper to 
give pliancy and at the same time force to the 
muscular and fibrous tissues. Wine, aromatics, 



APPLIED TO SURGERY. 161 

and camphorated spirits, on the use of which 
they generally insist so strongly, are less suita- 
ble than the preceding means: they seem to 
contract and harden the tissues, rather than to 
favour their extensibility by strengthening them 
and rendering their nutrition more active. Their 
application rarely succeeds in men already aged, 
in whom the articulations are dry and rigid af- 
ter old wounds. 

Such is the most rational method of treat- 
ment which it is possible to oppose to chronic 
arthrites in all forms, from incipient gout and 
the most trivial white swelling, to the most 
inveterate articular rheumatism, and the most 
considerable engorgement of all the tissues 
which compose or which surround a joint. If 
the disease has a disposition to return, as in 
gout and rheumatism, the antiphlogistic treat- 
ment, general and local, shortens the attacks, 
and diminishes their violence; it removes and 
prevents the formation of calcareous concretions 
and the disorganization of the parts. The econ- 
omy not accustoming itself then to an almost 
permanent irritation of the external parts, the 
metastases of this irritation on the viscera, in 
21 



162 PHYSIOLOGICAL DOCTRINE, 

consequence of which so many gouty persons 
die, do not take place. In a word, wherever 
there exists an inflammation of the articulations, 
whatever be the name which authors have given 
it, it is necessary to combat it by means of anti- 
phlogistics, and endeavour to extinguish it, 
unless, however, the organization, habituated 
to its presence, cannot support the privation 
without danger. But then it is always impor- 
tant to moderate the violence and to combat 
the too acute exacerbations of this irritation. 

A last observation, which will not fail to 
convince persons who reflect and who meditate 
on the results of the different therapeutical 
means which they employ, is, that when we 
apply the antiphlogistic treatment, and above 
all, local bleedings, with the most vigour and 
perseverance in the treatment of affections of 
the joints, we afterwards find, that the inflam- 
mations produced by these affections, pass less 
often into the chronic state and occasion the 
loss of the patients or necessitate the ablation 
of the parts. The following example, which 
was furnished me by M. Janson, seems to me 
to prove more and more, the astonishing success 



APPLIED TO SURGERY. 163 

with which local bleedings can be followed in 
the treatment of the most intense inflammations 
of the joints. A woman, on coming out of a 
bath, was taken, all of a sudden, with an excru- 
ciating pain in the left hip. In consequence of 
it she entered into the hospital. Two days af- 
ter, the painful member presented an elongation 
of two inches and a half, and all the symptoms 
of spontaneous luxation commenced. The head 
of the femur was on the point of leaving the 
cotyloid cavity. Leeches were applied about 
the hip, after this, blisters, and all motion of the 
thigh was forbidden the patient. Six days after, 
the pains were entirely relieved ; the limb short- 
ened itself and reassumed its proper form and 
direction. In about three weeks the cure was 
completed. 

§ III. Treatment of Cancer. In proving 
that scirrhous, cancerous, and other tumours of 
this kind, are the result of chronic inflammation 
and the alterations which this inflammation has 
determined in the nutrition of the parts affected, 
the new medical doctrine has already had a 
most happy influence on the practice of surge- 
ry. That fatality which seemed attached to 



164 PHYSIOLOGICAL DOCTRINE, 

the existence of abnormal tissues, and which 
led to the supposition that when once developed 
they were no more susceptible of being cured ; 
this fatality combatted with success by physio- 
logical physicians, is now generally destroy- 
ed. All practitioners have actually learned, 
that nature, aided by methodical assistance, can 
disembarrass herself, irritation being removed, 
of the more or less heterogeneous products of 
this same irritation. In fact, if pus, cellular 
engorgements, lardaceous, fibrous, cartilagin- 
ous, and fatty productions, etc. disappear after 
the inflammations which have caused their 
formation, why cannot scirrhous, cancerous, 
melanose, cerebriforme and other tissues dis- 
appear in the same manner? No argument 
can prove that it cannot be thus. The adver- 
saries of the new doctrine have confined them- 
selves to saying that they never have seen 
such cures. But they have only dissected worn 
out tumours in dead bodies, or extirpated by 
means of cutting instruments. Now, nothing 
proves that such tumours cannot be removed by 
absorption in other subjects. It is not proved, 
above all, that the morbid productions, of which 



APPLIED TO SURGERY. 165 

writers who have devoted themselves to patho- 
logical anatomy have given such excellent de- 
scriptions, were not absolutely more susceptible 
of being cured by the same process, if the pa- 
tients could have lived, or if, in place of opera- 
ting, our observers had employed therapeutic 
means in relation with the nature of the disease. 
There is more clinical experience, with as much 
evidence as we can acquire without having the 
diseased parts immediately under our eyes, to 
prove, that scirrhous or cancerous tumours have 
been cured by the employment of means proper 
to remove the irritation which has provoked 
and kept them up. 

There is one fact, nevertheless, the reality 
and importance of which, we should not con- 
ceal; it is, that the longer the irritation has 
existed in the parts, the more difficult it is to 
remove entirely the organic alterations which it 
has produced. This law is applicable not only 
to cancerous or scirrhous tissues, but to fibrous 
and cartilaginous productions, to cellular thick- 
enings, to tumefactions of the lymphatic gan- 
glions ; in a word, to all the products of in- 
flammation. It results from this, that when a 



166 PHYSIOLOGICAL DOCTRINE, 

tumour, which is thought to be cancerous, after 
having been for a long time indolent and sta- 
tionary, becomes gradually painful, and they 
still neglect to oppose it by a suitable treatment, 
it frequently resists all the efforts of art. But 
that which renders it incurable then by me- 
dicinal means, is less the presence in it of the 
tissues which form it, than the long continuance 
of the irritation, which is, to use the expression, 
identified with the organs, and which it is some- 
times impossible to remove. Nevertheless, as 
we possess a sufficiently great number of exam- 
ples of tumours already very old, which have 
yielded to a methodical treatment, we should 
constantly have recourse to it, and never aban- 
don the hope of succeeding. And even should 
we not entirely cure the patients by this treat- 
ment, we at least will have alleviated them, 
and, in diminishing the irritation, we render 
the success of the surgical operation more cer- 
tain. 

Among the cases of chronic irritations the 
products of which have already acquired the 
cancerous character, and which prove incontes- 
tably, the possibility of a cure by means of anti- 



APPLIED TO SURGERY. 167 

phlogistics and local bleedings, I shall confine 
myself to relating the following. 

A lady of sanguineous and nervous tempera- 
ment, aged twenty-five years, perceived, says 
Dr. Fallot, physician at Namur, that she had 
on the upper part of her right breast, a hard 
tumour, about the size of a peach kernel. She 
was then fifteen years of age; her health was 
perfect; and although she could not tell the 
cause of the tumour or the period when it was 
developed, she generally attributed it to a blow 
with the elbow which she had received in 
waltzing. A physician endeavoured to resolve 
the tumour by the aid of fumigations with 
boiling vinegar, mercurial frictions, and pills 
into which entered, very probably, the extract 
of hemlock. These remedies produced intense 
pains; she renounced them, and in 1817, the 
tumefaction equaled the size of a small apple. 
It was moveable under the skin, the colour of 
which had not undergone any change. We 
advised her to wear habitually a swan skin, in 
short, to keep the part at a mild and moderate 
warmth, and to remove every thing that could 
irritate it. In 1819, she married, and became 



168 PHYSIOLOGICAL DOCTRINE, 

a mother in 1820; at first, the milk from the 
breasts did not appear to exercise any influence 
on the tumour. Nevertheless, wishing to sup- 
press the secretion of this fluid, we prescribed a 
strict regimen and gentle laxatives. No acci- 
dent took place at first; but the sixth day of 
her accouchement, the breast became inflamed 
all of a sudden, without a known cause, and in 
spite of the application of leeches and cata- 
plasms, the pains became excruciating. Three 
small superficial abscesses formed and opened, 
and after having gone through a healthy sup- 
puration, they promptly cicatrized. During 
this inflammatory labour, the tumour had in- 
creased in size; it occupied a third of the breast, 
and, although always indolent, it troubled very 
much from its weight. At other times, but 
especially in the night, shooting pains were 
felt. A dozen leeches were then applied to it 
two days in succession, and stopped the pains, 
which reappearing in four months, yielded to the 
same means. The patient was always opposed 
to the repetition of the local bleedings; but five 
months after the application of the last leeches, 
the breast again became painful, and we cover- 



APPLIED TO SURGERY. 169 

ed it almost entirely with these animals. The 
bleeding was considerable and continued for 
twenty-four hours. It was not yet finished 
when the breast appeared already more light, 
and some hours after, the tumour had entirely 
disappeared.* 

If we consider that the tumefaction had lasted 
for ten years; that it was hard, moveable, in a 
measure isolated from the surrounding parts, 

and of such an obscure origin that we might 

> 

consider it as spontaneous, it will be difficult for 
us not to admit that it was formed of a genuine 
scirrhous tissue. Furthermore, the shooting 
pains of which it began to be the seat, announced 
either the beginning or imminence of the cancer- 
ous degeneration of the mass. Excitants had 
produced no other effect than that of augment- 
ing its yolume and rendering it more obstinate. 
Nevertheless, local bleedings were sufficient to 
make it disappear in so short a time. It is to 
be remarked, that whatever be the violence of 
the lancinating pains which invade the supposed 
cancerous tumours, the first applications of 



* Journal complimeniaire du Dictionnaire des sciences medical es, 
tome \2. 

22 



170 PHYSIOLOGICAL DOCTRINE, 

leeches, suffice, almost always, either to make 
them entirely disappear, or to diminish a great 
deal, their intensity. This important circum- 
stance presents itself again in all those cases 
where we have opposed local bleedings to 
scirrhi or cancers. 

Rose, of Havre, aged 23 years, of a remarka- 
bly lymphatic temperament, had, says Dr. Mau- 
rice Treille, at the age of 19, a child which she 
did not suckle. The health of this young person 
was made wavering from violent troubles; she 
experienced almost continued pains in the sto- 
mach ; her digestion of aliments was tedious 
and fatigueing, her stools irregular, her menses 
less than usual; finally white discharges suc- 
ceeded the sanguineous evacuation from the 
vagina, Six weeks after the invasion of these 
inconveniences the left breast became sensible, 
and a hard and moveable tumour made its ap- 
pearance. An anti-cancerous treatment was 
then employed without success, and they advi- 
sed the extirpation of the tumour. The patient 
refusing to submit to the operation, a host of 
remedies was administered to her. Under their 
influence her health continued to get worse, 



APPLIED TO SURGERY. 171 

and the breast was soon attacked with a rigid 
engorgement, little sensible to pressure, but the 
centre of which was the seat of lancinating 
pains. The right mamma, very soon afterwards 
presented a tumour of the same aspect as the 
preceding; pains of the stomach alternated with 
those of the breast; intense osteocopic pains 
were manifested; the muscles became soft; the 
integuments became discoloured and seemed al- 
tered. The features of the face, contracted and 
dried up, showed premature wrinkles. A diarr- 
hsea was manifested at times ; the palms of the 
hands were burning, the sleep disturbed and by 
no means refreshing: all announced the exis- 
tence of what is better called a cancerous 
cachexy. But although the patient even beg- 
ged for the operation, I feared to compromise 
the art by having recourse to it, and confined 
myself to prescribing the following remedies. 

At first the patient was to abandon the use 
entirely, of coffee, wine, and all spirituous li- 
quors. The aliments which I permitted her to 
make use of, were vegetables, and carrots espe- 
cially, milk, and messes prepared with this 
liquid. I directed her to take from three to 



172 PHYSIOLOGICAL DOCTRINE, 

eighteen ounces of sea water a day. Plasters 
of hemlock on the tumour; dry frictions all over 
the skin, and moderate exercise, completed the 
series of hygienic and medicinal means which 
seemed at first suitable. After employing them 
a month, the patient found herself better; she 
appeared less pale; the pains of the stomach 
disappeared; the tumours were of the same 
hardness and the same size; the pains w T ere still 
felt in them; but the plasters had determined 
an erysipelatous inflammation on the skin which 
they covered. When this inflammation was 
removed, I applied ten leeches on the left mam- 
ma and eight on the right. The parts were af- 
terwards covered with cataplasms made with 
the crumb of bread and the decoction of mal- 
lows and garden nightshade, which facilitated 
the draining of a thick, blackish blood. Two 
days after, the pains of the breasts disappeared, 
and the patient had slept the two preceding 
nights. To this treatment was then joined, 
pills of the extract of hemlock, aloes, and rheu- 
barb. Their use, combined with that of the 
sea-water, brought on a kind of diarrhsea, which 
I was often forced to arrest by stopping the use 



APPLIED TO SURGERY. 



178 



ofthese medicaments or diminishing their doses. 
The application of the leeches was repeated 
eight days after the first, and produced new re- 
lief. At this time the osteocopic pains were 
dispersed, and the tumours diminished in size. 
Encouraged by the first success, I applied fresh 
leeches every eight days or fortnight. After 
pursuing this treatment about five times, the 
bloom and embonpoint of the patient was re- 
stored, and there did not remain more than two 
tumours of a cartilaginous consistence in the 
left mamma, the size of which did not surpass 
that of a small pea, and which did not seem 
inclined to disappear entirely. Extirpation ap- 
peared necessary; but the patient was opposed 
to it, and the cure it seemed would be perma- 
nent without it. Three years after, Rose was 
married, she had a child which she suckled, 
and her health continued in a good state.* 

The detractors of physiological medicine, I 
may add of Dr. Treille, will no doubt be convin- 
ced, in going over this statement, that we do not 
exclusively employ leeches as they have assert- 
ed. They will be able to see, that w T e know 

* Jinnales dela medccine physiologiqne, tome 1. 



174 PHYSIOLOGICAL DOCTRINE, 

how to profit from all the means proper to 
establish a normal state. This reflection is 
just, and the cure of the patient whose history 
we have related, is a new proof of the skilful- 
ness of the practitioner who achieved it. Nev- 
ertheless, if cutaneous frictions, muscular exer- 
cise, and irritants directed to the digestive canal, 
constitute the valuable means of revulsion 
against chronic irritations of the external parts 
of the body, perhaps there may be found in the 
particular state of the patient of whom we speak 
the circumstances which counter-indicate the 
employment of some of these means. In effect, 
the habitual pains of the stomach and the irreg- 
ular diarrhsea with which she was for a long 
time affected, attested the existence of a gastro- 
enteric which might have been exasperated by 
the use of purgatives. Even when the pains 
of the stomach had ceased, it was to be feared 
that the drastic pills might reproduce them. 
The hemlock, besides, which acts especially by 
irritating the parts with which it comes in con- 
tact, is far from meriting the praises which 
have been accorded to it by the admirers of 
Stoercke; and, in the particular case which we 



APPLIED TO SURGERY. 175 

speak of, its internal use was able to produce 
some serious inconveniences. The observation 
of M. Treille is no doubt very important, since 
it furnishes an unequivocal proof of the possi- 
bility of the cure of supposed cancerous tumours 
already very advanced; but the following fact 
proves that we can attain this end by the aid of 
a much more simple treatment, and more exclu- 
sively antiphlogistic. 

A girl, aged 24 years, of a sanguineous and 
nervous temperament, entered into a hospital 
to make her noviciate as sister of charity. The 
following year she experienced lancinating pains 
in the left breast which returned at intervals, 
and discovered a small tumour which rolled 
under the fingers. Five or six months after, 
the tumour having acquired the size of a walnut, 
was painful to the slightest touch. The patient 
returned to her family, and during a year, many 
physicians of Nantz employed different inter- 
nal and local means without success; all the 
surgeons whom she consulted declared to her, 
that she had a scirrhous tumour in her breast 
which it was necessary for her soon to have 
extirpated. The disease vorv soon made new 



176 ' PHYSIOLOGICAL DOCTRINE, 

progress, and the young person, despaired of, 
came to the Hotel-Dieu of Paris. 

The tumour was at this period, hard, shrivel- 
led, unequal, sub-cutaneous, and of the size of 
a large goose egg, and occupied the middle and 
external part of the left brd'ast. It was the seat 
of habitual dull pains, and at other times intol- 
erable shooting pains took place and extended 
over the whole corresponding side of the breast, 
even to the shoulder. The body of the patient 
was extremely emaciated, her skin hot, dry, and 
covered with furfuraceous scales. A febrile ac- 
tion which supervened every evening continued 
a greater part of the night, and terminated by 
an abundant and clammy sweat. The patient 
had been for five or sbt months a stranger to 
sleep; she had experienced many attacks of 
hemoptysis, coughed continually, and threw out 
a great quantity of thick and puriform expecto- 
ration. Professor Lallemand of Montpelier, who 
was then at the Hotel-Dieu and had charge of 
the ward in which this patient was placed, con- 
tented himself for fifteen days, with prescribing 
for her, emollient drinks, julaps, etc. But the 
pains of the breast were more exasperated, like- 



APPLIED TO SURGERY. 177 

wise the symptoms of pulmonary affection ; the 
practitioner whom I have mentioned, applied 
eight leeches on her left breast; and a general 
bath and emollient cataplasms on the tumour 
were joined to the local bleeding. The pains, 
the fever and cough having diminished, four 
days after, he repeated the application of the 
leeches, and continued the use of baths and 
cataplasms. In about ten days, the tumour was 
less hard; the cough and expectoration had di- 
minished; and there existed no fever. The 
same treatment was continued. The tumour 
gradually softened, re-established itself, to use 
the expression, and in two months and a half, it 
was reduced to the size of a small filbert; the 
symptoms of pulmonary affection had entirely 
disappeared; and the patient had recovered her 
bloom and some embonpoint. Notwithstand- 
ing, a hundred and twenty leeches had been 
applied during a small interval, and the alimen- 
tary regimen was composed only of soups, broths 
of milk, rice, and other similar substances. Fi- 
nally, a month and a half after this period the 
tumour disappeared, and the patient attested 

23 



178 PHYSIOLOGICAL DOCTRINE, 

that her health had never been so prosperous.* 
In comparing these results of the antiphlo- 
gistic treatment with those that follow ordina- 
rily the employment of internal and external 
exciting means which are generally opposed to 
scirrhous tumours, it is easy to decide, to which 
of the two methods we give the preference. To 
the facts which I have cited, I have had joined 
a great number of examples of chronic and 
scirrhous engorgements of the axillary, cervical, 
or inquinal ganglions; of occult cancers of the 
parotid glands, the testicles, ovaries, and other 
organs of the same kind, which have been cured 
by the aid of local bleedings, baths, and an emol- 
lient regimen. These successes render more 
and more rare, the necessity of performing oper- 
ations for scirrhous and cancerous tumours, 
which are often serious, always painful, and 
which deprive the subjects of important organs. 
Sarcocele or sarco-hydrocele, for example, does 
not authorize any longer the use of an instru- 
ment on the testicle. None of the diseases of 

* Observations cliniques, suivies de quelques reflexions gener- 
ates sur les affections cancereuses, par M, Marechal, Montpellier, 
1821,in4to. 



APPLIED TO SURGERY. 179 

this kind which have been received in the mili- 
tary hospital of instruction at Strasburg, for 
more than six years, have resisted according to 
M. Gama, (chief surgeon and first professor in 
the establishment,) local bleedings alone, or 
assisted by revulsives, rest, and emollient fo- 
mentations. This gentleman avoids the appli- 
cation of cataplasms to the affected parts; he 
has found that their humidity and the thick 
glutinous deposit which they leave upon the 
skin, oppose the resolution of the tumour, by 
keeping the scrotum in a continual state of re- 
laxation and opposing its tonic action. The 
seminiferous conduits which return upon them- 
selves and partake of activity as soon as the 
first discharge is made, seem to remain inert 
under the influence of cataplams. " It would 
be exacting too much," says M. Gama, "to 
pretend to obtain a rapid success by this treat- 
ment; but if the cure requires some patience, 
it is at least, infallible." 

Let us add to these observations, that when 
the new medical doctrine shall be better known 
by surgeons; when, above all, glandular and 
cellular tumours shall be treated more methodi- 



180 PHYSIOLOGICAL DOCTRINE, 

cally at their commencement, the number of 
cancers will diminish considerably, and the ex- 
ample of like diseases that resist local bleedings, 
become more and more rare. 

Cancerous Ulcers, of which authors have 
given such faithful and horrible descriptions, 
yield frequently to a local antiphlogistic treat- 
ment. For, as I have already observed in this 
work, it depends generally upon quick and per- 
manent irritations exercised on the simple solu- 
tions of continuity, and which nothing announ- 
ced as having a tendency to assume this formi- 
dable character. It is thus, that my friend Dr. 
Blaquiere observed the beginning of a cancerous 
degeneration on the sore from a blister on the 
arm, that had been irritated with too much force 
and perseverance. The surface of the solution 
of continuity was already covered with solid and 
painful granulations; a pus of a bad nature 
flowed from it ; the borders, tumified and turned 
out, were surrounded by a livid engorgement of 
the neighboring integuments. The suppression 
of all irritants, simple dressings, and a moderate 
compression exercised on the part, sufficed to 
dispel all the symptoms, and to restore the sore 



APPLIED TO SURGERY. 



181 



to a normal state. If the disease had been 
more intense, and the irritation more lively, 
without doubt it would have been necessary to 
add local bleeding to the means employed. The 
following facts will show better than my reason- 
ings, the good effects that we may expect, in 
such difficult cases, to obtain from it. 

A man aged 50 years, of a sanguineous tem- 
perament, had always enjoyed good health, until 
at the age of 45 years, a small whitish pimple 
appeared in the middle of the border of the 
under lip. This pimple became cicatrieed the 
sixth day after an application of nitrous acid. 
The ulceration, nevertheless, returned a month 
afterwards, and remained stationary for four 
years, during which time scabs were formed, 
fell, or were removed and immediately replaced 
by others which met with the same treatment. 
At the commencement of 1819 the patient con- 
sulted a surgeon who cauterised the sore with 
fused nitrate of silver : on the removal of the 
scab, an ulcerated surface of sufficient magni- 
tude made its appearance. From that time the 
lip became tumified and painful. Another sur- 
geon having again sought to produce cicatrisa- 



182 PHYSIOLOGICAL DOCTRINE, 

tion by the application of corrosive sublimate, 
all the symptoms augmented : the pain became 
more intense and concentrated ; the borders of 
the ulceration turned out; and a considerable 
loss of substance was sustained to prevent the 
mouth from being closed. Professor Lallemand 
found the patient in this state, and saw, that 
from the aspect of the sore, the hardness and 
overturning of its borders, which appeared lar- 
daceous, and from the lancinating nature of the 
pain, it was one of those cancerous ulcers for 
which, until now, no other remedy than that of 
ablation had been known. Nevertheless, before 
employing such a remedy, which does not pre- 
vent entirely a relapse, he wished to try such as 
had obtained for him, happy results in analo- 
gous cases. Eight leeches were applied around 
the lip, they were replaced by an emollient cata- 
plasm, and a general bath was administered. 
Four days after, the lip was less hard and less 
painful, the same number of leeches was again 
applied, which produced a new diminution of 
symptoms. The next day a third and similar 
application was made : the cataplasm had been 
continued, and a cicatrice began to form. Final- 



APPLIED TO SURGERY. 183 

ly, after one month of this kind of treatment, 
the cicatrization was nearly complete; pain had 
almost entirely subsided ; and there existed but 
a very small part of the border of the ulcer the 
the sise of a pea, which, hard, unequal and pro- 
jecting above the cicatrice, retarded its reunion. 
It was removed with a bistoury : the next day 
the little sore was closed, and several days after- 
wards, the patient was enabled to quit the hos- 
pital. 

The following observation presents an exam- 
ple no less remarkable, of the happy effects of 
the antiphlogistic treatment in cases of phage- 
denic cancerous ulcers. 

A man, aged 55 years, was affected with an 
ulcer occupying the nose from its free margin 
to the root. The left ala of this organ was 
completely destroyed. On the right side, the 
destruction was less advanced; the anterior half 
of the division had disappeared. Above the 
opening of the right nasal fossa, existed a nar- 
row and elongated perforation which communi- 
cated with the interior of the cavity. The bor- 
ders of this ulcer were thick, whitish, turned 
outwards in certain points, and lardaceous in 



184 PHYSIOLOGICAL DOCTRINE, 

others. A blackish scab resembling charcoal, 
covered the whole surface of the sore; the pain 
here was at times lancinating. The disease 
made its appearance two years before, by a 
small pimple under the left ala of the nose, 
which, having been several times removed, 
was converted into an ulcer, the progress of 
which was rendered more rapid frorn the use of 
local irritants and caustics. Two applications 
of leeches, at one time, eight, and another, six, 
emollient cataplasms, and general bathing, ac- 
complished so much in thirteen days, that the 
cicatrice covered already the inferior part of the 
ulcer, as also the division of the nose. The per* 
foration on the right side was obliterated : there 
were but several points of the surface of the 
cartilages to be cicatriced, which were already 
covered with fleshy granulations of a red and 
vermillion colour; every thing led to the con- 
clusion, that from the rapid formation of the 
cicatrice, in two or three days the cure might 
be considered as complete.* 

These facts show in an incontestable man- 
ner, the accuracy of what I have before said 

* Work cited by M. Marechal 



APPLIED TO SURGERY. 185 

concerning the irritation which exists during 
the development of cancerous ulcers. Is it not 
evident, that if local bleedings and emollient 
applications are sufficient to cure the disease 
when it is already far advanced, the same rem- 
edies might stop it in its beginning, prevent it 
from making any progress, and smother it, as it 
were, in its origin? It results also from the 
foregoing remarks, that these eating ulcers, 
even when they have destroyed the parts to a 
great extent, are not necessarily incurable, and 
that it is not always indispensable either to de- 
stroy their surfaces by means of caustics, or to 
remove them with a cutting instrument, Inde~ 
pendently of the danger of poisoning, which 
follows the use of arsenical ointment, this reme^ 
dy is sometimes incomplete in its cure of small 
ulcerations, and it would be useless to emproy 
it in those of greater extent. A cutting instru- 
ment, it is true, presents fewer inconveniences, 
but recourse cannot be had to it when the ulcer 
extends over a great part of the face, and rests 
almost immediately on the cartilages and bones. 
Then, the surgeon is almost always the idle 
spectator of the progress of the disease, and thq 
24 



186 PHYSIOLOGICAL DOCTRINE, 

slow and cruel destruction of the patient. The 
white-hot iron, which is,without doubt,the most 
energetic means that can be possibly used under 
these painful circumstances, often fails, either 
from its action not having been carried suffi- 
ciently deep, or from the impossibility of its 
penetrating into all the infractuosities of the 
sore. But whenever this operation fails, the 
disease redoubles its fury, and its progress is 
much more rapid than at first. This result 
shoujd not astonish one : in fact, it is very sim- 
ple, that the application of caustic, of fire, or 
the action of a cutting instrument, when they 
do not wholly destroy the affected parts, aug- 
ment the irritation of which they are the seat, 
and by this means, give an uncommon violence 
to all the symptoms. 

• The ancients, knowing the danger which the 
exasperation of the ulcers tvhich now occupy 
our attention, caused the patient to run, estab- 
lished as a precept, never to touch them, but to 
disorganize their entire surfaces. But the name 
of noli-me-tangere which they gave to these 
lesions, is not, at the present day, entirely ap- 
plicabla to them : without doubt, you must not 



APPLIED TO SURGERY. 187 

■ • 

touch them with irritants or caustics, but it can 
be done with emollient substances to some ad- 
vantage, aided by local bleedings, revulsives 
and a suitable regimen. 



188 PHYSIOLOGICAL DOCTRINE, 3 

* 

Chapter VIIL 

«- 
Sympathetic phenomena produced by external 
chronic irritations. 

When irritations of the external parts of the 
body are prolonged, they exercise on the organ- 
ic movements of the animal economy, an in- 
fluence which is of great importance -for the 
surgeon to be acquainted with. The patient 
who is in the first instance, in a normal state of 
health, sees his strength gradually diminish, his 
body grows thin, the skin discolours, becomes 
dry, stiff, and gradually covered with scurfs : 
every thing indicates a great alteration impres- 
sed upon the nutritive actions, If the disease 
consists in an old sore, the suppuration of which 
is abundant, or in the caries of a bone ; in a 
word, in an irritation not accompanied by pro- 
found degeneration of the affected tissues, the 
paleness of the integuments do not present any 
thing remarkable. But when chronic inflam- 
mation determines the formation of a scirrhous 
or cancerous tissue, it may almost always be ob- 
served, that the complexion of the patient, while 



APPLIED TO SURGERY. 189 

he grows pale, partakes of a straw colour, very 
easily known, and which is sufficient sometimes 
to announce the nature of the malady. 

It is equally to be remarked, that when a part 
is affected with chronic inflammation, it exer- 
cises a special influence over other similar parts 
of the economy. Thus, inflammation accom- 
panied by a cancerous degeneracy of one breast, 
tends invariably to propagate itself to the oppo- 
site breast. Chronic arthritis, seldom, if ever, 
continues in one articulation without extending 
itself, sooner or later, to the other joints. The 
forms of this malady, which are known by the 
names of gout, articular rheumatism, and white 
swelling, furnish multiplied proofs without end, 
of the exactness of this proposition. Finally, 
irritations of the muscles, aponeuroses, lig- 
aments, blood vessels, secreting organs, &c. 
have a remarkable disposition to extend them- 
selves to other organs charged with analogous 
secretions, to other vessels of the same kind, 
and to other divisions of the fibrous tissue. — 
This law, already distinguished by Bichat, may 
offer exceptions ; but it rests incontestably on 
almost the whole of pathological observations. 



190 PHYSIOLOGICAL DOCTRINE, 

There is another phenomenon quite as im- 
portant, and which merits no less than the 
preceding to fix all the attention of the physi- 
ologist and practitioner : it is, that the organic 
system which is particularly affected in the ac- 
tively diseased part, is that which tends to be- 
come so in those organs over which it exer- 
cises a sympathetic action. The mode of irri- 
tation which constitutes the primitive disease, 
is also that which will develope itself in the 
part that is secondarily affected. When the 
capillary blood vessels, for instance, are particu- 
larly irritated and there exists a real inflamma- 
tion, the sympathetic lesion determined by this 
affection will be equally inflammation. If the 
patient, on the contrary, is attacked with neu- 
ralgia, the nerves tend equally to become the 
seat of irritation in the other organs. Finally, 
ganglionites, white degenerations, and the or* 
ganization of abnormal tissues, are so many 
diseased modifications which the parts sympa- 
thetically affected are disposed to contract. In 
a word, an irritation being given, its existence 
Continued for a time more or less long, is e- 
nough to communicate to every part of the 



APPLIED TO SURGERY. 191 

body, and especially to those which are united 
by a close sympathy with the actual seat of dis- 
ease, a strong disposition to contract a similar 
irritation which would give rise to the same pro- 
ducts. If the sympathetic influence exercised 
by a diseased organ, is not sufficiently powerful 
to determine alone a similar irritation on other 
parts, a foreign cause of the most feeble kind, 
will be enough to produce the effect. Thus it 
is in individuals affected with white swellings, 
contusions, even slight, of another articulation, 
will occasion here a similar swelling. It is 
shown, that men do not contract, in general, 
but such affections as they are already disposed 
to by their organization ; but irritation, in de- 
veloping itself, renders this organic disposition 
more active and gives greater vigour to the ap- 
pearances which characterise the various tem- 
peraments. * 

Independently of these general phenomena 
produced by external chronic irritations, these 
irritations determine notable changes in the 
action of the principal viscera of the econ- 

* Boyer principes generaux de physiologic pathologique Paris, 
1821,in8vo. 



192 PHYSIOLOGICAL DOCTRINE, 

omy. It seems in the first place, that they give 
more activity to the digestive organs. The 
patients consume, during the first periods, and 
when the symptoms are moderated, more ali- 
ment, than when in a normal state. The entire 
animal organization,and particularly the viscera, 
are sympathetically excited by local irritation. 
The living economy appears to have need of 
more abundant materials, in order to repair the 
daily losses which it sustains. But very soon, 
whether from the stomach and small intestines 
being irritated after the excessive labour of 
which they are the seat, or from the prolonga- 
tion of the sympathetic excitation determined 
by the external lesion producing the same effect, 
it is seen that the digestion becomes fatigueing 
and painful. The tongue turns red at its point 
and borders; the skin becomes dry and burn- 
ing; the pulse small and frequent. At one 
moment the appetite continues, and at the next, 
it is diminished to nothing. In the evening a 
slight febrile exacerbation is ebservable, with a 
warmth in the palms of the hands, as also in 
the bottom of the feet, and sweats more or less 
abundant and viscous at the superior parts of 



APPLIED TO SURGERY. 193 

the body. These phenomena have been named 
hectic fever. Like all affections of the same 
kind, this fever is the immediate result of the 
excitation of the digestive canal, and of the 
heart and brain; excitation which is itself de- 
termined, in the case which now occupies us, 
by the external lesion. 

Nevertheless, irritation after having invaded 
the stomach and the beginning of the intestines, 
gradually propagates itself towards the ileum, 
stops at the ileo-csecal valve, finally penetrates 
the caecum and extends to all the large intes- 
tines. As these progressions take place, diarr- 
hsea is manifested. At first rare, irregular, and 
not returning but after some excess of regimen, 
it becomes at last permanent, and, if I may use 
the expression, continual. The appetite very 
often returns at this period, with much more 
vivacity, as the accelerated contractions of the 
digestive canal renders the stay of the aliments 
in the stomach and small intestines very short. 
Thirst is almost inextinguishable; violent colics 
are experienced three or four hours after meals, 
when the alimentary matter enters into the 
cavity of the large intestines. The losses 
25 



194 PHYSIOLOGICAL DOCTRINE, 

which the patient sustains, and the distur- 
bances determined in the nutritive actions by 
local irritation, and small and abundant evacua- 
tions, sweats which are prolonged and bathe 
the whole body, finish by wasting the strength, 
and we may say, dry up the whole machine, 
and death succeeds a more or less advanced 
state of marasmus. 

There are several remarkable varieties to be 
observed in the successions of these affections, 
the most ordinary course of which I have just 
traced. In certain individuals, acute or violent 
irritations determined by external lesions, such 
as extensive wounds, are prolonged to a mode- 
rate degree, but without ceasing to excite a 
manifest febrile action; it would seem to be a 
traumatic fever that persisted and degenerated 
into a hectic fever. In a far greater number of 
individuals, traumatic fever seems to subside 
completely in the beginning, and every thing 
seems to predict a happy recovery. Neverthe- 
less, the local lesion not terminating itself, 
whether it be from foreign bodies remaining in 
the parts, cartilages, tendons or bones deprived 
of their envelops that should exfoliate, it is soon 



APPLIED TO SURGERY. 195 

observed, that the irritation passes into a chronic 
state, and reproduces the internal excitation: 
then an interval more or less long, separates the 
cessation of the primitive acute fever, from the 
appearance of the hectic fever. 

Whatever may be the modifications of this 
kind which take place, the phenomena them- 
selves do not vary. In the first place we con- 
stantly observe the gastro-enterite manifest itself, 
then irritation of the large intestines, or colitis. 
Intervals more or less long, according to the 
constitution of the patients, separate the differ- 
ent periods of the affections, one from the other. 
In some individuals, gastro-enterite is slow to 
develop itself; the organization seems to oppose 
an obstinate resistance to the development of 
the internal super-excitation which the affected 
part tends to produce. And when this first in- 
flammation is manifested, it may remain a very 
long time in a very feeble state, and not exer- 
cise any influence on nutrition, until diarrhsea 
comes on. It has been observed, that this great 
destroyer of the economy does not affect certain 
persons until for several years. Whilst in others, 
it brings on death in a few months: such is the 



196 PHYSIOLOGICAL DOCTRINE, 

great difference that nature has made in differ- 
ent subjects, between the strength of the con- 
stitution and the firmness of the equilibrium of 
action of the different organs. 

It would be, however, a great and sometimes 
dangerous error to think, that external chronic 
irritations direct their actions exclusively to the 
alimentary canal. I have already observed on 
the subject of traumatic fever and its complica- 
tions, that in persons previously affected with 
irritations in other organs, there follows, in 
place of a simple fever, inflammations of these 
organs, which in their turn, give new force to 
the febrile action and complicate the primitive 
disease. But this mechanism again appears 
in the cases which we now consider. In sub- 
jects whose respiratory organs, for instance, are 
irritable, the mucous membrane of the bronchiae, 
the pulmonary parenchyma or the pleura, often 
become the seat of active irritation sympatheti- 
cally determined by the external chronic phleg- 
masia. In other cases, the liver, spleen, kid- 
nies, and the peritoneum, by their excessive 
irritability, form centres of action, towards 
which the sympathetic irradiations direct them- 



APPLIED TO SURGERY. 197 

selves in an especial manner; and their inflam- 
mation shortly adding itself to that of the exter- 
nal parts, renders more rapid, the destruction of 
the forces and the progress of marasmus. It 
should not be forgotten, that these varied lesions 
are in a measure accidental: they depend more 
upon the particular state of the economy, and of 
the affection of certain organs, than the regular 
exercise of the laws of organization. Moreover, 
irritation, after having propagated itself from the 
place primitively affected towards a more or 
less important organ, does not continue its 
march the less towards the digestive canal, and 
we may constantly observe before the death of 
the patients, the ordinary signs of gastro-ente- 
rite. 

There is a phenomenon unfortunately too 
common in large hospitals, and which merits 
here a special consideration. It often happens 
after great operations, and particularly after 
amputation performed in cases of white swel- 
lings, caries or other chronic diseases of the 
members, that the patients, whose general state 
of health appeared very good, die in several 
days or weeks. This fatal issue is announced 



198 PHYSIOLOGICAL DOCTRINE, 

by the continuation of the thinnes, feebleness 
and inappetence which precedes the operation. 
The traumatic fever, the developement of which 
generally follows this, is continued in a less de- 
gree, without its being possible to know the 
cause. On opening the dead body, one of the 
internal parts, such as the pleura, the parenchy- 
ma of the lungs, the liver, the peritoneum or the 
spleen, but most commonly the pleura, is found 
filled with pus, and in a more or less advanced 
state of disorganization. * The most attentive 
examination of the subject, often, will not lead 
to a knowledge of the lesion that should pro- 
duce death. A dry cough is quite common, a 
feeling of heaviness in one side of the chest, 
and a dull sound which this side gives to per- 
cussion, announce in a manner sufficiently pos- 
itive, the suppuration of the pleura ; but these 
signs do not become evident until this mem- 
brane is already filled with a large quantity of 
liquid and no further attempts can serve the 
patient. It is the same with the pain in the 
hypochondrise or in the whole of the abdominal 
cavity, which accompanies the suppuration of 
the liver, the spleen, or the peritoneum. Lesions 



APPLIED TO SURGERY. 199 

of this kind are very serious and almost con- 
stantly fatal. 

The profound study of the living organisa- 
tion alone permits us to unveil the mechanism 
by which affections of this kind are produced. 
If it is considered, that these internal suppura- 
tions do not manifest themselves until after 
chronic diseases which have for a long time 
caused the patient to suffer, and fatigued the 
economy, it will appear reasonable that they 
are the result of stimulation sympathetically ex- 
ercised by the irritated external organs, on the 
parts which are their seat. The super- excitation 
which is produced under these circumstances, 
often establishes itself with slowness, without 
producing a considerable disturbance in the 
functions of the affected organs, and without 
provoking an acute and violent febrile agitation. 
Then practitioners may mistake the too fugitive 
signs of internal lesion, and the opening of the 
body will shew him disorders, the existence of 
which he had not foreseen. This may happen 
with subjects who die of external chronic in- 
flammations without ever having been aided by 
art. But, let a person operate ; let the diseased 



200 PHYSIOLOGICAL DOCTRINE, 

part be retrenched at a time when some inter- 
nal organ begins to be irritated; then this irri- 
tation, far from ceasing, continues its march, 
making new progress ; the acute inflammation 
and traumatic fever which follow the opera- 
tion, instead of contributing to extinguish, gives 
to it new energy, by the sympathetic stimula- 
tion and circulatory movement which they de- 
termine. Perhaps, at this time, the sudden 
withdrawal of a focus of supuration already of 
long standing, still disposes the economy to 
furnish a similar secretion elsewhere. However 
it may be, we cannot consider the internal ab- 
cesses of which we now speak, as independent 
of the external lesions to which they succeed : 
at the period of the operation, they either ex- 
isted already, but were of too little magnitude 
to be discovered, or the organs which they in- 
vaded were not yet but sympathetically irritated, 
but with such force, that this irritation might not 
have ceased by the ablation of the part which 
had provoked it, and that, to the contrary, had 
made new progress after the operation. 

The theoretical explications established in 
this chapter are not speculative and hypothetic 



APPLIED TO SURGERY. 201 

cal; they evidently consist in the simple, and 
we may say literal expression of a great num- 
ber of known facts. I have only pointed out in 
exposing the succession of phenomena, how the 
organs act to produce them; and this manner 
of explaining, which is employed by physicians 
and chemists, appears to me to be the only one 
suitable to medicine. The philosophical method 
of observing and drawing consequences from 
observations, is the same in all sciences. As to 
the proofs of the exactness of my assertions, 
they may be found plentifully at the bed-side of 
the sick and on the dead body. One may see 
at every instant during the life of the subjects, 
the signs of the lesions of which we have spo- 
ken, and follow step by step their successive 
development; and after death we may find tra- 
ces of them on the affected organs. 

On opening the bodies of persons who have 
sunk under the influence of external chronic 
irritations, in the first place we find disorgani- 
zation produced by phlogosis in the affected 
member, which varies according to the surround- 
ing tissues and the progress of the disease. In- 
ternally, we discover the disorders which result 
26 



202 PHYSIOLOGICAL DOCTRINE, 

from inflammations sympathetically determined 
to other organs than the alimentary canal, and 
which were the most sensitive and irritable; such 
as, the lungs, the liver, the serous membranes, 
&c. These disorders consist either in large 
abscesses, or in a more or less considerable red- 
dening and thickening, or in diversified produc- 
tions and organic degeneracies. We arrive, 
finally, at the lesions constantly developed in 
the digestive canal. These may vary almost 
without end. These are frequently brownish 
patches more or less extensive, disseminated in 
the stomach and small intestines. Accompa- 
nied by varicose development of the vessels, 
with softening, disorganization, and thickening 
of the mucous membrane. Those patches are 
large in the stomach, small and rare in the first 
parts of the small intestines, more numerous 
and crowded together in the vicinity of the ileo- 
cecal valve. It is not rare to find in this place 
the intestinal tunics thickened, degenerated 
into lardaceous and melanose tissues, presenting 
on their internal surface, ulcers more or less 
large, at the bottom greyish, the borders of 
which are red, hard, protruding, shaped to a 



APPLIED TO SURGERY. 208 

point, and which furnish a bloody and sanious 
suppuration. In the large intestines the same 
disorders exist; we find there almost always a 
multitude of small ulcers in groups, and which 
seem to have for a base, the mucous follicles of 
those organs very much developed. 

These alterations are so much the more ex- 
tensive and profound, as the disease has been 
more tedious, and disorganization has had time 
to operate more completely. I still recollect 
the examination of a soldier for some time affec- 
ted with a caries of the tibia, and who died in 
consequence of an irritation of the digestive 
viscera, after having been operated upon with 
the greatest success by M. Beclard, surgeon 
major and professor to the military hospital of 
Instruction at Strasburg. On opening the 
corpse, we found the mucous membrane of 
all the digestive canal reddened, thickened and 
engorged to such an extent, that the intestines, 
opened and spread upon a table, resembled a 
fleshy membrane. It is rare that the encepha- 
lon presents any trace of irritation. The pa- 
tients almost always continue the free exercise 
of their intellectual faculties to the last. Nev- 



204 PHYSIOLOGICAL DOCTRINE, 

ertheless, when melancholy, unwillingness to 
die, or other motives of disappointment act with 
force, we see the brain give signs of excitation, 
and we find after death, either serosity in the 
ventricles, an albuminous exudation on the 
arachnoid, or more profound disorders which 
announce the existence of an intense cerebral 
excitation already of long standing. 



APPLIED TO SURGERY. 205 

Chapter IX. 

Treatment of internal irritations which com- 
. plicate chronic surgical diseases. 

The theoretical principles exposed in the 
preceding chapter, seem to me to throw a new 
light on the causes and seat of internal lesions 
which manifest themselves almost constantly in 
important surgical diseases of long standing. 
This theory should have an equal effect in 
making us adopt a treatment more simple and 
efficacious against the complications which now 
occupy us. Surgeons, in treating patients af- 
fected with chronic diseases in whom the vis- 
cera begin sympathetically to inflame, still 
combat the hectic fever with bark and its pre- 
parations ; want of appetite, with bitters ; diarr- 
hea, with astringents and opium ; feebleness, 
with tonics in every form ; and internal acciden- 
tal phlegmasia^ which come on during this state 
of debility, with vesicatories and almost always 
exciting drinks. To restore lost strength, give 
tone to the stomach, contract the mucous folli- 
cles of the large intestines, combat the adyna- 



206 PHYSIOLOGICAL DOCTRINE, 

mic phlegmasia, by removing local debility of 
the vessels, such are the general indications 
which they propose to fulfil. It seems that the 
whole of Brownism had taken refuge in this 
portion of the healing art. But, what are the 
most ordinary results of this practice? Exaspe- 
ration of the symptoms, and the rapid death of 
the patients. 

Always when a surgical lesion tends to be- 
come chronic, it is necessary to examine the 
nature of this lesion, its seat, the manner in 
which it progresses, and the effects that may be 
expected from the internal and external treat- 
ment which is proposed to be employed. The 
temperament, the age, the strength and actual 
state of the constitution of the patient, are of 
great importance in determining what course 
to pursue. If it is thought that the patient is 
sufficiently strong to resist the violence and pro- 
longation of irritation ; — if, besides, the local 
lesion is of such a nature as to be able to sub- 
side spontaneously, or by well directed efforts 
of art: — -we should most assuredly temporise and 
put in use such therapeutic means as may be 
most suitable. But when the result of the cal- 



APPLIED TO SURGERY. 207 

culation of the practitioner is opposed to this 
proceeding, and the patient is threatened with 
immediate danger, or the local disease seems to 
be of an incurable nature otherwise than by 
operating, it is necessary without further delay, 
to have recourse to the latter. It is easily seen 
how much experience and skill are necessary 
to solve problems of this kind ; — how necessary 
it is to have a profound knowledge of the laws 
of the animal economy, the resources of nature, 
and the means of art, to avoid passing an er- 
roneous judgment ; — how much it is necessary, 
in fine, to be circumspect and reserved, in order 
not to be contradicted by the result. What 
compassion should those practitioners inspire, 
who affect to pronounce at first sight and be- 
fore any previous inspection, judgments, which 
chance renders sometimes correct, but which 
are much more often invalidated by experience ! 
It should be observed, besides, that in cases of 
uncertainty, we do not place the patient in any 
danger by having recourse at first to hygienic 
and medicinal means and in delaying, for there 
will still be time to administer, as soon as we 



208 PHYSIOLOGICAL DOCTRINE, 

shall have acquired the conviction of the inu- 
tility of these remedies. 

After these reflections, it is easy to under- 
stand how vain were the discussions which 
were raised among surgeons, relative to the 
period which is most favourable to the success 
of operations during diseases. The opposite 
opinions advanced by two military surgeons, 
on the subject of amputations which the 
wounds of fire-arms necessitate, are known. 
This question is at the present day, defi- 
nitely resolved, and \ye constantly amputate 
limbs at the instant of the wound, whenever 
the extent of the lesion does hot permit us to 
preserve them, and when the patient is not 
plunged into such a state of stupor or profound 
debility as not to be able to stand the operation. 
Relative to chronic diseases, Bell has maintain- 
ed, that it was not necessary to amputate unless 
the patient became very much debilitated, and 
was already affected with habitual looseness and 
colliquative sweats. Such erroneous precepts 
have never been followed by many practitioners: 
they have feared, and with just reason, that the 
operation would only serve to aggravate the 



APPLIED TO SURGERY. 209 

affections, or that the wounds which they left 
after them could not heal in patients too much 
exhausted to furnish suppuration afresh* 

Nevertheless, the same persons who have 
made these judicious reflections, assert, that 
the state of debility of the patients is singularly 
favourable to the success of the amputations 
which they have performed after chronic ar- 
thritis ; and that they had then less to fear the 
inflammatory affections which succeed these 
operations. It is true, that in very feeble pa- 
tients, acute inflammations do not have ordina- 
rily the same violence as in robust and vigorous 
men; but these slight inflammations produce 
frequently in debilitated subjects, more danger- 
ous effects than intense phlegmasia determine 
in strong men. The latter resist very intense 
external irritations; the former succomb often 
in consequence of the most trifling inflamma- 
tions. In robust subjects, we can oppose violent 
inflammations by powerful antiphlogistic means; 
in very feeble patients, we cannot employ with- 
out fear, the smallest sanguineous evacuations. 
Supposing even, that it really existed, this ad- 
vantage that is thought to be obtained in not 
27 



210 PHYSIOLOGICAL DOCTRINE, 

operating until an advanced stage of the disease, 
will be more than compensated by the pains to 
which the patient is condemned until he appears 
sufficiently weak, and by the internal inflamma- 
tions which he is exposed to contract whilst he 
is submitted to the influence of a considerable 
focus of irritation exercised on the whole econ- 
omy. Besides, is it not always more easy to 
combat by means of sanguineous evacuations, 
diet, and emollient drinks, the acute inflamma- 
tions which may succeed operations, and to 
remove those latent irritations which so often 
develop themselves in the viscera of subjects in 
whom external phlegmasia? have existed for a 
long time ? It is sufficient to give a glance at 
the modifications in the vitality of all the parts 
of the organism, caused by these phlegmasia?, to 
be convinced how unreasonable it would be to 
prolong without motive the disturbance which 
they determine in the most important functions. 
It is constantly repeated, that feeble patients 
will recover from wounds made during opera- 
tions, more easily than others; but it is not said 
how many patients before arriving at the state 
of feebleness desired, die, either of pretended 



APPLIED TO SURGERY. 211 

acute fevers, or of inflammations which they 
would not have contracted, if, operated upon 
sooner, they had been restored to health: it is 
not said how many patients do not arrive at 
that happy state of debility until affected by gas- 
tro-enterite, pneumonia, pleurisy, or other chron- 
ic inflammations which hinder the performance 
of operations which might have been practised 
with success at a less advanced period of the 
disease: it is not said, finally, how many pa- 
tients perish in consequence of eixormous ab- 
scesses, produced, as we have seen heretofore, 
by those internal inflammations, and which 
might have been easily cured if these formida- 
ble affections had not been allowed time to 
develop themselves. Thus it is, that observa- 
tion and experience itself, can be dangerous 
and deceptive to those who are too ready to 
deduce from them, general principles and rules 
of practice. 

It is necessary then, I repeat, to operate on 
subjects affected with chronic surgical diseases, 
as soon as these maladies are proved to be in- 
curable otherwise than by this remedy. By 
acting in this manner, we prevent certainly the 



212 PHYSIOLOGICAL DOCTRINE, 

manifestation of the internal irritations which 
they sympathetically determine, and which be- 
come almost inevitably fatal. 

I have pointed out in one of the preceding 
chapters, the general plan of treatment which it 
is proper to oppose locally to chronic surgical 
irritations ; it only remains for me to expose 
the means of combatting the internal affections 
which complicate them when it has been im- 
possible to operate before their appearance. 

It is to be observed, first, that an appropriate 
local treatment, in diminishing the intensity of 
the irritation of the parts and in shortening its 
duration, is the means the most efficacious which 
we can oppose to the development of internal 
lesions which it tends always to determine. 
We observe in cases of chronic irritation, what 
is so evident in those of acute inflammation: 
just as the traumatic fever is lessened and some- 
times prevented by local bleedings, in like man- 
ner the internal irritations and hectic fever are 
kept off or rendered less intense by the use of 
the same treatment. 

The regimen of patients affected with exter- 
nal chronic diseases ought to be rigid: light 



APPLIED TO SURGERY. 218 

and nourishing aliments ; mucilaginous or acid- 
ulated drinks; small quantities of old Bordeaux 
wine during meals if the stomach performs its 
functions well, are the substances which they 
should use. It is proper to keep open the 
bowels by emollient injections; to favour the 
cutaneous transpiration by the aid of general 
baths and garments of wool proportioned to the 
severity of the season ; to oppose the concentra- 
tion of the vital movements to the interior, by 
means of moderate exercise appropriated to the 
nature of the disease and the strength of the 
patient. We should never but with great cir- 
cumspection, direct revulsives to the alimentary 
canal: this organ is too much disposed to be- 
come the seat of a fatal irritation, for one not to 
fear accelerating the development of this affec- 
tion, and rendering it more intense, by placing 
exciting substances in contact with the diges- 
tive mucous membrane. It is, on the contrary, 
to the external parts, that revulsions are direct- 
ed with the most success: the means indicated 
above are proper to produce them: we may 
join to their use, frictions exercised on the skin 



214 PHYSIOLOGICAL DOCTRINE, 

by flannel or soft brushes, and other operations 
of the same kind. 

If, nevertheless, the gastro-enterite develops 
itself, it becomes necessary to retard or lessen 
its progress by means of emollient fomentations 
on the abdomen, gummy drinks, a very strict 
regimen, and even some applications of leeches, 
repeated as often as the renewal of the symp- 
toms require and the strength of the patient 
will allow. When diarrhsea manifests itself, it 
is an indication that we ought to confine our- 
selves to prescribing aliments which are nour- 
ishing in a very small quantity, and without 
furnishing great quantities of stercoracious ma- 
terials ; such are rice, sago, and other analogous 
substances. When, finally, in spite of the em- 
ployment of these remedies, the forces diminish 
more and more, and the alvine evacuations, 
likewise the habitual sweats, seem to exhaust 
the economy completely, it only remains for 
the surgeon to sustain some time longer, the 
remains of an extinguishing life; and tonics 
may be administered internally. 

When the lungs, the pleura, the liver, or any 
other important organ is at first the particular 



APPLIED TO SURGERY. 215 

seat of sympathetic irritation determined by ex- 
ternal lesions, it is proper to combat this irrita- 
tion as if it was the result of any other cause: — 
that is to say, by means of antiphlogistics and 
local bleedings proportioned to the intensity of 
the phenomena, and the forces of the patient. 

The progress of the disease having rendered 
necessary the use of surgical instruments, what 
preparation ought the patient to undergo, finally, 
to insure the success of the operation? Enlight- 
ened practitioners have for a long time since 
sanctioned the empirical and rediculous method 
of bleeding, purging, and bathing all patients 
previous to performing the amputation of a limb, 
the extraction of a vesical calculus, the incision 
of a fistula in ano, etc. The surgeon enlight- 
ened by pathological physiology, confines him- 
self to examining with attention the state of 
all the organs and the manner in which all the 
functions are executed. Having acquired by 
this investigation an exact knowledge of the 
different parts of the patient on which he is to 
operate, he determines easily what should be 
done in order to prevent the accidents which 
may succeed the operation. 



216 PHYSIOLOGICAL DOCTRINE, 

If the patient is otherwise healthy, the only 
reasonable preparation consists in employing 
means the most proper either to diminish the 
sensibility, or to moderate the circulatory move- 
ment if it is violent and appears disposed to be- 
come more so, or finally, in producing a state 
of relaxation in the gastric passages, capable of 
preventing the too rapid and too intense devel- 
opment of gastritis. Baths, bleeding, some 
emollient lavements, diluent drinks, and a sooth- 
ing regimen, are sufficient to fulfil these indica- 
tions, to which, no doubt, it is not necessary to 
attach very great importance, but it will be 
dangerous to neglect them entirely. I know 
many surgeons of very great expertness in the 
execution of operations, and who are notwith- 
standing less successful than others, because 
they do not pay sufficient attention to methodi- 
cally preparing their patients before the opera- 
tion, and because they do not prevent and 
combat with sufficient attention and energy, 
the inflammatory affections which succeed 
operations. 

If the person on whom we are to operate is 
in a feeble state of health, accompanied with 



APPLIED TO SURGERY. 217 

notable disturbances in the most important func- 
tions, the preparation which we ought to put 
in use ought to have for its object, the combat- 
ting of the irritations of the internal organs. 
Thus, for example, if the patient who is to 
undergo an amputation, has the skin dry and 
burning, the stomach painful, the point and 
borders of the tongue red, intense thirst, a fre- 
quent and hard pulse; beware of operating 
under such circumstances. Abstain, above all, 
from having recourse to aliments for the purpose 
of increasing the forces, to sudorifics for estab- 
lishing the cutaneous transpiration, to purga- 
tives, with the intention of disembarrassing the 
intestinal canal of supposed bilious or mucous 
saburral materials, finally, to bark, intended to 
prevent the return of the febrile action. Such a 
treatment, which some practitioners still adopt 
in the cases of which we speak, would be emi- 
nently dangerous; it would have for its almost 
inevitable effect, the exasperation of the symp- 
toms; and even when it does not produce all 
the evil of which it is susceptible, whilst pre- 
cious time is lost by administering in vain, the 
favourable period for the operation passes. It 
28 



218 PHYSIOLOGICAL DOCTRINE, 

is proper then at this time, to liave recourse to 
general baths, soothing drinks, epigastric bleed- 
ings, and to a regimen composed of a small 
quantity of aliments that are light and easy of 
digestion. These means do not enfeeble the 
patients; far from it: the gastric phlogosis be- 
ing diminished, the secretions are re-establish- 
ed; nutrition recovers a part of its activity; 
and the return of a colour in the skin and some 
firmness in the muscles, announce that the 
economy is in a state for supporting the opera- 
tion. 

Analogous means ought also to be employ- 
ed, if other organs than the digestive canal 
become the seat of a sympathetic irritation de- 
termined by the external disease. The pectoral 
organs, the liver, the spleen, and the whole of 
the abdominal cavity should then be examined 
with great attention. If the patient cannot take 
a full inspiration without experiencing pain; — if 
he is troubled with a cough more or less fre- 
quent; — if percussion of the thorax does not 
give, above all, a clear sound ; — if the stetho- 
scope announces the existence of some lesion 
in the organs of respiration and circulation: — 



APPLIED TO SURGERY. 219 

expect to see an external inflammation arise, 
and thus rob you as well as the patient, of the 
fruit of the best executed operation. It is there- 
fore of the highest importance to combat at this 
time, with energy, the already developed or only 
imminent irritations of the organs, by means of 
local bleedings, baths, soothing drinks, a strict 
regimen, and revulsives — such as vesicatories, 
setons, moxas, cauteries, etc. The same atten- 
tion ought to be paid to the exploration of the 
abdominal viscera, and the same perseverance 
in destroying the very last vestiges of their 
phlegmasia. It is only after being assured of 
the proper state of all the viscera, that we are 
permitted to operate, and that we can do it with 
some security. It is here that medical know- 
ledge extended and founded on a wholesome 
physiology, procures for surgeons who possess 
it, signal success; whilst under the same cir- 
cumstances, operators limited to manual action, 
meet, in spite of their dexterity, only with inev- 
itable reverses. 

I have already observed, that if operations 
performed on account of chronic surgical dis- 
eases are not always successful, it is in a great 



220 PHYSIOLOGICAL DOCTRINE, 

measure because they perform them at a period 
when the irritations which require them have 
all their intensity, and exercise the most power- 
ful action on the animal economy. The entire 
organization is then sympathetically affected by 
the phlogosed and more or less profoundly alter- 
ed tissues. There exists in all the organs a 
very striking disposition to irritation ; and when 
the economy is suddenly deprived of the heat 
of inflammation to which it was habituated, the 
most light causes serve to develop others, which 
sometimes even seem to arise spontaneously. 
These secondary phlegmasia© make progress 
so much more rapid, and are so much more 
promptly fatal, as they have their seat in parts 
already disposed a long time since, to allow 
themselves to be destroyed by them. 

Applying these reflections to cancerous dis- 
eases, which are those in which relapse is most 
frequent, it is easy to demonstrate, that the 
same causes favour and determine the produc- 
tion of these affections. When we extirpate a 
cancerous or other ulcer, we do it commonly at 
a period when the local irritation is in all its 
force, and when the rest of the animal econo- 



APPLIED TO SURGERY. 221 

my, a long time since subdued by the sympa- 
thetic action of the affected organ, is already 
more or less profoundly vitiated. All the tissues 
being endowed then with a greater susceptibil- 
ity to contract irritation, are disposed, for this 
reason, to become easily the seat of new can- 
cers. 

Experience has proved, that it is especially 
on the part primitively affected, that relapses 
take place. Reasoning explains this phenome- 
non in a manner sufficiently satisfactory. In 
effect, it could hardly be thought, that the tis- 
sues which have been for many years in contact 
with a tumour or a cancerous ulceration, may 
not have participated, or may not at least have 
contracted a strong disposition to the irritation 
which constitutes the disease. Now, this slight 
irritation, or only this disposition to irritation 
can, as it appears, exist without the texture of 
the parts being altered to the point of necessi- 
tating their ablation. It is thus that we find 
around cancers, portions of cellular tissue be- 
come yellowish, others infiltrated by serosity. 
others, finally, in which the density is manfestly 
augmented; muscular and aponeurotic fibre* 



222 PHYSIOLOGICAL DOCTRINE, 

have frequently experienced an alteration in 
their consistence and even in their organization. 
Now, is it surprising that the parts thus affected 
should become, after the destruction of the prim- 
itive disease, the seat of a secondary disease 
more grievous still? Ought not the new cancer 
to develop itself with so much more rapidity, as 
the derangement of the vital movements, the 
traces of which I have just pointed out, is longer 
continued? Ought not the tumour or consecu- 
tive ulceration to make, besides, more rapid pro- 
gress than the primitive disease, since we find 
the parts which it invades and the entire econ- 
omy already disposed to receive and give them- 
selves up without resistance to its ravages ? 

What are then, in the cases where extirpation 
of the cancer is judged indispensable, the means 
the most proper to insure the success of the 
operation and prevent the return of the disease? 
The means are incontestably those which suc- 
ceed best in bringing about the cure when it is 
not thought advisable to operate. Previous to 
to removing a tumour or a cancerous ulcer, it 
will be proper, according to my view, to make 
always use of an antiphlogistic treatment : 



APPLIED TO SURGERY. 223 

leeches should be applied in a number more or 
less great on the tumour or around the ulcer, 
emollient cataplasms, baths, and soothing drinks 
should be prescribed, and we should not make 
use of a cutting instrument until the lancinating 
pains have been completely removed, and until 
the proper colour of the patient has announced 
the re-establishment of the nutritive functions. 
In a word, we should only operate at a period 
when the sympathetic phenomena produced by 
the cancer have very much diminished in inten- 
sity, and when the vivid irritation of the tumour 
or of the ulcer no longer existing, these diseases 
will only constitute lesions almost entirely for- 
eign to the living organization, and the destruc- 
tion of which cannot bring on any notable dis- 
turbances in the functions. By the aid of local 
antiphlogistic means, the disease will be confi- 
ned, the tissues which border upon those which 
are disorganized will be restored to their natural 
state, and the chances of a return of the cancer 
will be greatly diminished. 

The ulceration of cancerous tumours does not 
contraindicate the treatment alluded to, and 
which ought to be considered as preparatory to 



224 PHYSIOLOGICAL DOCTRINE, 

the operation. I have often observed the suppu- 
ration become better under its influence, the 
edges of the wound settle down, the pains 
disappear, and the ulcerated tumours the abla- 
tion of which we scarcely dared to attempt, so 
certain did the relapse appear, become suscep- 
tible of a permanent cure. The extreme feeble- 
ness of the patient is far from constituting 
always an invincible obstacle to the employ- 
ment of an antiphlogistic treatment. There 
exists a great number of examples of persons 
already reduced to a very advanced state of 
marasmus, in whom local bleedings and suita- 
ble hygienic and medicinal means, have raised 
the forces and re-established the nutrition, by 
causing to cease or by diminishing the irrita- 
tions which destroyed the one and altered the 
other. Besides, if the patient is too feeble for 
it to be possible to make use of emollient med- 
ications, it is very probable that he will not be 
able to support the operation with advantage, or 
we will not to be able to succeed on account of 
the profound affection and state of debility of 
all the organs. It would not then be proper to 
submit such a patient to pains that are useless 



APPLIED TO SURGERY. 225 

and more proper to hasten his destruction than 
to effect a cure. 

Not only ought a well directed antiphlogistic 
and revulsive treatment to be employed to pre- 
pare the patient for the operation in the case of 
cancer, but it is necessary still to continue the 
use of this treatment after the ablation of the af- 
fected parts, in order to confirm the health of the 
patient. It is proper to watch the person oper- 
ated upon, for whole years; — to prescribe for 
him a diet gently emollient; — to oblige him to 
take baths frequently; — and to keep the bowels 
constantly regular by means of mild purgatives 
and injections. Warm cloihing, living in the 
country, moderate exercise, and tranquility of 
mind, are each of the circumstances which fa- 
vour powerfully the return and establishment of 
perfect health. Some weeks before the opera- 
tion, an issue ought to be established and con- 
tinued with care, in order to supply as much as 
possible, the place of the irritation and suppura- 
tion of which the economy is made to stand in 
need, in cancers which have existed for a long 
time. If the patient contracts some new irrita- 
tion, the practitioner ought to combat it prompt- 
30 



226 PHYSIOLOGICAL DOCTRINE, 

ly and with energy, in the end to prevent its 
passage into a chronic state, and a cancerous 
degeneration to which the parts affected will be 
still disposed. Finally, if the wound itself, or 
the tissues which cover the cicatrice already 
formed, should become, in spite of these pre- 
cautions, the seat of an eruption consecutive to 
the cancer, it becomes proper to oppose to this 
new evil the treatment which has succeeded 
against the primitive affection. And although 
notwithstanding success be almost impossible, 
we obtain at least relief and a prolongation of 
the existence of the patient. 

Analogous means ought to be employed in 
cases of scrofula: that is to say, before opera- 
ting on subjects in whom the lymphatic system 
is irritated, it is necessary previously to remove 
this irritation, to give to the sanguineous appa- 
ratus its energy, and to continue this treatment 
a long time even after the operation, in order to 
insure the complete cure of the patient. In a 
word, in all the chronic phlegmasise of our 
organs, surgical operations constitute only a 
secondary means of curation: the practitioner 
ought only to have recourse to them after hav- 



APPLIED TO SURGERY. 227 

ing vainly employed more gentle means; and 
even when he makes use of instruments, it is 
the methodical administration of the assistance 
of medicine and the rigorous observance of the 
rules of hygiene, which insures and confirms 
the success of operations. 



FINIS* 



3V°l^ 






